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PERSONALITY SUBTYPES OF INDIVIDUALS WITH TRAUMATIC CHILDHOOD
SEPARATIONS FROM ATTACHMENT FIGURES

By

Johanna Catherine Malone

A DISSERTATION

Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Psychology

2009

ABSTRACT

PERSONALITY SUBTYPES OF INDIVIDUALS WITH TRAUMATIC CHILDHOOD
SEPARATIONS FROM ATTACHMENT FIGURES

By
Johanna Catherine Malone
The goal of this research (composed of three studies) was to examine personality
characteristics and identify personality subtypes of adolescents and adults with childhood
histories of traumatic separations from a parent. Previous work from attachment theory
and developmental psychopathology suggest that distinct developmental trajectories may
lead to different styles of personality adaptation in both adults and adolescents with a
history of attachment disruption. Randomly selected psychologists and psychiatrists
provided data on 236 adolescents and 201 adults with histories of traumatic separations
using a personality pathology instrument designed for use by clinically experienced
observers, the Shedler-Westen Assessment Procedure (SWAP-II and SWAP-II-A). Using
a Q factor analysis, ﬁve distinct personality subtypes were identiﬁed in both the
adolescent and adult sample (Studies l and 2). Subtypes common to both adults and
adolescents included: internalizing/avoidant, psychopathic, and resilient. The adult
sample included an emotionally dysregulated subtype, while within the adolescent
sample two subtypes characterized by emotional dysregulation emerged: impulsive
dysregulated and immature dysregulated. Finally, within the adult sample, a
hostile/paranoid subtype was identiﬁed. In Study 3, initial support for the validity of the
subtypes was established based on Axis I and Axis II pathology, adaptive functioning,
developmental history, and family history variables. The clinical implications of these

ﬁndings are discussed in terms of treatment and case formulation.

ACKNOWLEDGMENTS

My dissertation was completed in the context of many levels of support. First, I
would like to thank my dissertation co-advisors Dr. Drew Westen and Dr. Alytia A.
Levendosky. Next, I would like to thank my committee members including Dr. Robert
Caldwell, Dr. Brent Donnellan, Dr. Adrian Blow, and Dr. Thomas Luster. The data from
this dissertation came from two NIMH grants (R01-MH62377 and R01-MI-I62378) to Dr.
Westen. Next, Michigan State University provided multiple fellowships (Dissertation
Completion Fellowship and University Distinguished Fellowship), which allowed more
time to devote to the project. Finally, I would like to thank my friends and family for

their care and inspiration.

iii

TABLE OF CONTENTS

LIST OF TABLES ....................................................................... vii
REVIEW OF THE LITERATURE ................................................. 1
Introduction ................................................................... 1
Theoretical Background... 4
Developmental Pathways to Personality Subtypes: The Medlatmg
Role of the Internal Working Model ....................................... 7
Understanding Personality Pathology: Moving to a Dimensional
Approach ..................................................................... 9
A Categorical Approach: DSM—IV .............................. 10
Dimensional Approaches.............................................. 11
The Five Factor Model .................................... 12
Shedler Westen Assessment Procedure ................. 13
Personality Pathology in Adolescence ..................................... 15
Attachment and Personality Pathology .................................... l6
Assessing Personality Subtypes l9
AIMS OF THE CURRENT STUDY ............................................... 20
OVERVIEW OF THE METHODS .................................................. 21
STUDY 1

IDENTIFYING PERSONALITY SUBTYPES OF ADOLESCENTS
WITH TRAUMATIC CI-HLDHOOD SEPARATIONS FROM

ATTACHMENT FIGURES ........................................................... 23

Method ........................................................................ 23
Participants ........................................................... 23
Procedures ............................................................ 23
Measures ............................................................. 25

Results ......................................................................... 28
Characteristics of Participating Clinicians in the Overall
Sample ................................................................ 29
Characteristics of Adolescent Patients in the Overall
Sample ............................................................... 29
Characteristics of Clinicians Describing Adolescent Patients
with Histories of Separations .................................... 29
Characteristics of Adolescent Patients with Histories of
Traumatic Separations ............................................. 30
A Composite Portrait of Adolescents with Histories of
Traumatic Separations .............................................. 31
Q-Analysis and Personality Subtypes with Adolescent
Personality Constellations .......................................... 32

iv

STUDY 2
IDENTIFYING PERSONALITY SUBTYPES OF ADULTS WITH
TRAUMATIC CHILDHOOD SEPARATIONS FROM ATTACHMENT

Method ........................................................................ 36
Participants ........................................................... 36
Procedure & Measures ............................................................ 36

Results ................................................................................................. 37
Characteristics of Participating Clinicians in the Overall
Sample ................................................................ 37
Characteristics of Adult Patients in the Overall Sample ....... 37
Characteristics of Clinicians Describing Adult Patients with
Histories of Traumatic Separations .............................. 38
Characteristics of Adults Patients with Histories of
Traumatic Separations ............................................................ 38
A Composite Portrait of Adults with Histories of Traumatic
Separations... ... 39
Q- Analysis and Personallty Subtypes with Adult Personal1ty
Constellations... ... ... 40

STUDY 3

VALIDATING THE IDENTIFIED PERSONALITY SUBTYPES OF
ADOLESCENTS AND ADULTS WITH TRAUMATIC CHILDHOOD
SEPARATIONS FROM ATTACHMENT FIGURES USING EXTERNAL

CRITERIA... 43
Personality as an Orgamzat1onal Framework ........................... 43
Intemalizing/Avoidant Personality Subtype ......................... 43
Psychopathic Personality Subtype .......................................... 46
Emotionally Dysregulated Subtypes ...................................... 49
Hostile/Paranoid Subtype ........................................................ 54
Resilient Subtype .................................................................... 55
Hypotheses Regarding Criterion Variables ............................... 57
Method ................................................................................................ 59
Participants ........................................................... 59
Procedures ........................................................... 59
Measures ............................................................. 59
Results ......................................................................... 59
Validating the Personality Subtypes .............................. 59
Demographic Variables by Subtype .............................. 61
Contrast Analyses ................................................... 62

Incremental Validity of the Traumatic Separation
Personality Dimensions ............................................ 65
GENERAL DISCUSSION OF THE THREE STUDIES ............................... 66
Adolescent and Adult Traumatic Separation Subtypes .................. 67

Personality Subtypes and Comorbid Psychopathology: Axis I and II

Criterion Variables ........................................................... 70
Personality Subtypes in Relation to Developmental History and
Family History Criterion Variables ........................................ 72
Incremental Validity ......................................................... 77
Limitations .................................................................... 78
Directions for Future Research ............................................ 80
Clinical Implications ......................................................... 82
Conclusion .................................................................... 83
APPENDICES ................................................................................................ 85
Appendix A. Tables ............................................................................ 85
Appendix B. Measures ....................................................................... 123
BIBLIOGRAPHY ......................................................................................... 1 60

vi

LIST OF TABLES

Table 1. Characteristics of Adolescent Patients with and without Childhood

Traumatic Separations from Attachment F1gure 86
Table 2. Composite SWAP-II-A Description of Adolescents with Traumatic
Separations from Attachment Figure (N = 236) 88
Table 3. Correlations among the 5 Adolescent Personality Subtypes 89
Table 4. Personality Subtypes of Adolescents with Traumatic Separations from
Attachment Figures in Childhood 90
Table 5. Characteristics of Adult Patients with and without Traumatic

Childhood Separations from Attachment Figures. . . . . . .. ...................................... 98
Table 6. Composite SWAP- 11 Description of Adults with Lengthy Traumatic
Caregiver Separations (N= 203). 100
Table 7. Correlations among the Adult Personality Subtypes. . . . . . . 101
Table 8. Personality Subtypes in Adults with Traumatic Separations from
Attachment Figures in Chlldhood 102
Table 9. Percent of Sample Meeting Criteria for Subtypes as a Function of

Presence or Absence of Traumatic Separatlon 109
Table 10. Demographic Variables by Adolescent Personality Subtype ............ 110
Table 11. Demographic Variables by Adult Personality Subtype. . . . . . . . 111

Table 12. Axis I and Axis II Comorbidity by Adolescent Personality Subtype... 112

Table 13. Developmental and Family History by Adolescent Personality

Table 14. Axis I and Axis II Comorbidity by Adult Personality Subtype. . . . . 115

Table 15. Developmental and Family History variables by Adult Personality

Table 16. Correlations of Adolescent Subtypes with Criterion Variables N=236 118
Table 17. Correlations of Adult Subtypes with Criterion Variables N=203 ....... 120

Table 18. Hierarchical Linear Regression Predicting Adolescent Global

vii

Adaptive Functioning from Demographic Variables (Step 1), Childhood
Trauma (Step 2), and Personality Subtypes (Step 3).. 121

Table 19. Hierarchical Linear Regression Predicting Adult Global Adaptive

Functioning from Demographic Variables (Step 1), Childhood Trauma (Step
2), and Personality Subtypes (Step 3).. ... 122

viii

Review of the Literature
Introduction

During childhood, a traumatic separation ﬁom an attachment ﬁgure (i.e., primary
caregiver) can leave a child feeling frightened, helpless, and without the physical and
emotional resources to care for him or herself. The study of traumatic separations as a
form of attachment disruption has been of heightened interest during periods of pervasive
societal crisis. For example, during World War II, Anna Freud and Dorothy Burlingham
documented the “despair” of children separated from their parents (Freud & Burlingham,
1943, 1974). Later in the twentieth century, researchers began studying the
developmental trajectories of children placed in Romanian orphanages under the
Ceaucesku regime (O'Connor, Bredenkamp, Rutter, & The English and Romanian
Adoptees Study Team, 1999; Zeanah, Smyke, Koga, & Carlson, 2005). More recently,
research has focused on children growing up in the American foster care system with
regards to biopsychosocial functioning (Dozier, Lindhiem, & Ackerman, 2005; Dozier et
al., 2006; Stovall & Dozier, 1998).

Findings across these studies reveal a diversity of outcomes following the
experience of a traumatic separation. Research suggests that the attachment disruption
itself leads to a set of changes that may be independent or interrelated at different levels,
including changes in the HPA axis (Dozier et al., 2006; Meinlschmidt & Heim, 2005),
internalizing pathology (Heim & Nemeroff, 1999; Heim & Nemeroff, 2001; Vorria,
Rutter, & Pickles, 1998a), externalizing pathology (Kendler et al., 1996; Kendler, Sheth,
Gardner, & Prescott, 2002; Vorria et al., 1998a), and dissociative symptomatology

(Kobak, Little, Race, & Acosta, 2001). In addition, attachment disruptions are associated

with indiscriminate afﬁliation in children and insecure and disorganized forms of
attachment (Chisholm, 1998; Chisholm, Carter, Ames, & Morison, 1995; O'Connor,
Rutter, & The English and Romanian Adoptees Study Team, 2000; O'Connor et al., 1999;
Scharf, 2001; Zeanah, Smyke, & Durnitrescu, 2002; Zeanah et al., 2005).

It is likely that this wide range of biological, psychological, and social outcomes
associated with traumatic separations are not associated with only one personality proﬁle,
particularly given that variables such as internalizing and externalizing pathology
themselves are generally thought of as personality variables (often called negative
affectivity or neuroticism, and low conscientiousness or constraint, respectively). The
minimal amount of research assessing personality in this population suggests that
traumatic separations are associated with Borderline and Avoidant personality disorders
(PD) (Arbel & Stravynski, 1991; Bradley, 1979; Reich & Zanarini, 2001). Each of these
studies considered just one PD, and thus did not account for the range of personality
proﬁles that might be associated, in part, with the experience of the traumatic separation.
In addition, research suggests that the PDs currently found in the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association,
2000) may not adequately represent a full range of personality pathology (i.e., disordered
personality). A number of studies have found that personality pathology is often assessed
in clinical settings but may or may not lead to a PD diagnosis for a variety of reasons,
including the fact that most personality pathology is subthreshold and that most patients
identiﬁed in research with a PD receive the nondescript diagnosis of PD Not Otherwise
Speciﬁed (Morey et al., 2007; Westen & Arkowitz-Westen, 1998; Widiger & Trull,

2007).

Given the wide range of outcomes associated with traumatic childhood
separations from attachment ﬁgures, the present study sought to identify personality
subtypes, including, if present, both normal and pathological variants, of adult and
adolescent patients who experienced traumatic separations in childhood. Knowledge of
personality subtypes may be crucial in addressing the speciﬁc needs and experiences of
such individuals within clinical setting.

Attachment theory and research provide an overarching framework for
understanding the signiﬁcance of traumatic separation for personality development.
Therefore an overview of the attachment theory, its signiﬁcance for the creation of
persistent relational schemas (i.e., Internal Working Models), and the role of attachment
in regulating affect is provided. However, traumatic separations have ramiﬁcations not
only for attachment classiﬁcation but also for personality as a whole. They lead to a range
of developmental pathways likely due to genes, environments, and gene environment
interactions (Caspi, Roberts, & Shiner, 2005). While the extant research suggests that
there is heterogeneity in the way people’s personality is affected by disrupted attachment,
that heterogeneity is likely to be patterned, not random, because there are going to be
some characteristic ways (e. g., turning into a psychopath, becoming self-loathing and
depressed, or somehow managing to be resilient despite it) that are common to different
groups of survivors. It was expected that some of these patterns would be common to
adults, whereas some may be distinct to adolescents or adults.

In this research, personality was assessed using a psychometric instrument
designed for clinically experienced observers, which encompasses both pathological and

non-pathological personality characteristics and hence can identify both pathology and

resilience. After seeking to identify these subtypes empirically, external and predictive
validity were considered using a priori hypotheses regarding psychopathology, adaptive
functioning, developmental history, and family history variables that were expected to
distinguish a valid classiﬁcation (Robins and Guze, 1970).

Theoretical Background

Attachment theory emphasizes the importance of the parent child relationship for
later healthy psychological development. Interactions between the attachment ﬁgure and
infant result in the infant’s development of Internal Working Models (IWMs) or
representations of self and other relating to the expression of personality (Bowlby, 1969).
Functioning as unconscious schemas, IWMs serve as relatively stable templates for
expectations about relationships. Thus, an early caregiving relationship characterized by
instability, neglect, or abuse could lead the child to develop negative feelings about him-
or herself and to expect negative treatment from others (George, 1996; Lyons-Ruth &
Jacobvitz, 1999).

Ethological and psychoanalytic theory inﬂuenced Bowlby’s development of
attachment theory (Bowlby, 1969, 1973, 1980). Bowlby was interested in substantiating
his theory through the use of observable phenomena. Bowlby (1969) argued that natural
selection favored proximity maintaining behaviors in young children that fostered both
their survival and learning. In further work he chose to focus on separations, loss, and
threats of abandonment because these events have readily observable effects, can be
observed in other species, and are so pervasive that understanding their effects would be

immediately useful in clinical settings (Bowlby, 1973).

Relevant to the study of traumatic separations, attachment theory has stressed the
importance of both proximity and autonomy in development (Bowlby, 1988; Slade &
Aber, 1992). As the child develops autonomy, he or she can use the parent as a “secure
base” to return to after exploring the environment. Therefore the consistent presence of
the parent grants opportunities for both exploration and reunion. This idea developed in
part out of the psychoanalytic work of Margaret Mahler who theorized that as part of
normative development children practice both pushing the parent away and pulling the
parent close, in a sense rehearsing the experience of separation, which later develops into
autonomy and individuation (Bretherton, 1987; Fonagy, 2001).

Ainsworth developed an observational lab paradigm called the Strange Situation
and was able to identify three different attachment strategies utilized by children to
connect with their attachment ﬁgures (Ainsworth, Blehar, Waters, & Wall, 1978). In the
Strange Situation the child faces a series of separations and reunions with a caregiver.
The behaviors that children display during these reunions represent their view or IWM of
the relationship (Main, Kaplan, & Cassidy, 1985). Securely attached children show
mutual responsiveness and pleasure with the caregiver, and effective use of proximity
maintaining behaviors. Insecure avoidant children appear disinterested and exhibit
neutral behavior towards the parent. The parent child interactions appear impersonal and
unemotional. Insecure ambivalent children use whiny attempts to gain attention,
reﬂecting resistance and fear. Patterns of interactions with the primary caregiver lead to
expectations regarding both how they will be responded to, and how they will respond to

others. IWMs of self and other serve as a mechanism for dealing with stress in the world,

whether through emotion, cognition, or behavior (Easterbrooks, Davidson, & Chazan,
1993)

The initial three classiﬁcations of the Strange Situation paradigm (Avoidant,
Secure, and Ambivalent) were later expanded in order to explain contradictory behaviors
that were seen in some infants indicating the absence of a coherent attachment strategy
(e. g. running to a caregiver but then turning away when the caregiver approaches,
freezing behaviors, or the mixing of different strategies) (Main & Solomon, 1990). These
behaviors reﬂect what is now called disorganized attachment. Main and Hesse (1990)
hypothesized that disorganized attachment originates in the fn'ghtening or frightened
behavior of the primary caregiver. The presence of disorganized attachment reﬂects more
than mere parental insensitivity, instead indicating either maltreatment or frightening
behavior (e. g. traumatic separation or loss) (van Ijzendoom, Schuengel, & Bakermans-
Kranenburg, 1999). While the focus of this study is not on the classiﬁcations of
attachment, researchers report that in response to an attachment disruption, a child will
typically develop either an insecure or disorganized attachment pattern (Kobak, 1999;
Nakash-Eisikovits, Dutra, & Westen, 2002; Solomon & George, 1999).

Research considering attachment in adults and adolescents often uses the Adult
Attachment Interview (AAI). The AAI is used to classify four states of mind regarding
attachment to early primary caregivers. It relies on outside coders to identify processes,
which its developers believed to be outside of conscious awareness (Hesse, 1999).
Narratives of Secure/autonomous individuals are coherent, demonstrating a balanced
view of attachment experiences. The narratives of Dismissing individuals tend to be

incoherent, contradictory, and overly normalize negative attachment experiences.

Narratives of Preoccupied individuals are characterized as incoherent with a view of the
past that is angry, fearful, or passive. Finally, individuals given the qualiﬁer Unresolved
(which may be used with any of the primary three descriptors but is generally associated
with insecure forms of attachment) demonstrate lapses of reasoning around experiences
of loss or abuse (Hesse, 1999). Some researchers have found that adult attachment
strategies may be relevant for understanding personality pathology (F onagy et al., 1996;
Westen, Nakash, Cannon, & Bradley, 2006). Importantly, the Unresolved classiﬁcation
relates speciﬁcally to the experience of attachment disruptions. 1

Developmental Path ways to Personality Subtypes: The Mediating Role of Internal

Working Models

Bowlby (1973) himself emphasized the relevance of attachment disruptions to
personality development. He described “homeorhetic pressures” (i.e., environmental and
constitutional factors) that help maintain an expected developmental pathway even in the
presence of minor disruptions. However, lengthy or recurring periods of separation, or
the experience of loss may not only temporarily divert personality development from an
optimal path, but may also lead to an entirely different path of development. Therefore
Bowlby conceptualized traumatic separations as inﬂuencing not only IWMs but also
having additional consequences for personality as a whole.

In addition, Bowlby (1973) noted that personality characteristics that are adaptive
in one environment might be maladaptive in another. He even hypothesized that certain
attachment strategies in early childhood would relate to certain personality styles later in
life. He theorized that the anxious-ambivalent attachment strategy would relate to a

personality style that was clingy, anxious, and demanding. In contrast, the anxious-

avoidant attachment strategy was hypothesized to relate to a personality style that lacked
warmth and connectedness within interpersonal relationships. Research studying
attachment and personality has largely borne out these hypotheses (Crawford et al., 2006;
Kobak & Sceery, 1988; Nakash-Eisikovits et al., 2002; Westen, Nakash et al., 2006).

Personality pathology can also be viewed as a set of phenotypes resulting from
environmental experiences (e. g., attachment disruptions) that moderate gene expression
(Caspi et al., 2005). Individuals are born with temperamental traits inﬂuenced by their
genotype, and the expression of these predispositions is modiﬁed by environmental
factors (e.g., teratogens, relationships, poverty, etc.), which in turn produces behavior that
creates different environmental experiences, such as exposure to delinquent peers. This
widely held view is supported by research considering gene-environment interactions in
which differences in sensitivity to environmental factors are based on allelic variation
(Shiner & Caspi, 2003).

While some IWMs represent the overactivation of the attachment system (e.g.,
ambivalent or preoccupied IWMs), others suggest that the attachment system is down-
regulated (e.g., avoidant or dismissing IWMs). Both of these responses may be adaptive
to a given context in childhood but then become ineffective as the child develops into
adolescence and adulthood, leaving their original family context (Fischer etal., 1997).
For example, an overactivated attachment system develops when the infant learns that the
caregiver responds most positively when he or she overuses normative proximity
maintaining behaviors (e.g., crying, clinging, calling) (Mikulincer & Shaver, 2008). In
contrast, the down-regulated attachment system develops when the infant learns that the

caregiver is likely to respond negatively or even withdraw when he or she exhibits

normative proximity seeking behaviors. This results in the less frequent use of such
behaviors, because they are ineffective and are associated with an undesired outcome.
Emerging research suggests that the IWMs most chronically accessed across
development are likely to form one of the stable aspects of personality (Mikulincer &
Horesh, 1999; Mikulincer & Shaver, 2006; Shaver & Mikulincer, 2005). Therefore,
IWMs likely mediate the experience of the traumatic separations and later outcomes of
personality.
Understanding Personality Pathology: Moving towards a Dimensional
Approach

With the understanding that traumatic separations have consequences for the
developing personality, but that not all people respond to the experience in the same way
due to genes, environments, and gene-environment interactions, personality outcomes
were expected to be heterogeneous. Therefore, personality subtypes would be useful in
organizing the diversity of clinical presentations. In order to assess personality, it was
necessary to ﬁnd an approach that would adequately represent the nuance of personality
found in clinical practice. In addition, personality needed to be assessed in a way that was
inclusive of resilient outcomes. Recent research has suggested that in clinical settings
personality pathology may best be assessed using a dimensional approach, rather than the
categorical approach found in the DSM—IV. Here, personality pathology refers to
clinically relevant personality problems that may or may not result in a DSM—IV Axis II
PD diagnosis. The necessity for personality pathology (i.e., disordered personality) to
have a broader deﬁnition than the PDs listed in the DSM-IV will be described in the

following section, which brieﬂy reviews some of the identiﬁed shortcomings of the

categorical approach. This is followed by a brief description of two dimensional
approaches to assessing personality and personality pathology: the Five Factor Model
(F F M) and the Shedler Westen Assessment Procedure (SWAP).

A Categorical Approach: DSM-IV

The current method of diagnosing PDs found in the DSM—IV relies on a
categorical approach in which individuals meet cut-offs for certain disorders. The DSM-
IV is a multi-axial diagnostic system, on which PDs are listed on Axis II due to their
more pervasive nature, as opposed to other forms of psychopathology, which are assumed
to be more transient. The DSM-IV PDs are divided into three clusters: Cluster A
(Paranoid, Schizoid, Schizotypal) refers to individuals who appear “odd or eccentric”;
Cluster B (Antisocial, Borderline, Histrionic, and Narcissistic) refers to individuals who
are “dramatic, emotional, and erratic”; Cluster C (Avoidant, Dependent, and Obsessive-
Compulsive) refers to individuals who appear “anxious and fearful.” The DSM—IV
provides a syndromal approach to considering personality pathology, which means that
each disorder is viewed as being composed of constellation of personality characteristics
that are interrelated (Westen & Shedler, 2007).

Problems with the current DSM-IV approach to diagnosing PDs include the lack
of adequate empirical support, arbitrary symptom cutoffs, and the use of a categorical
approach that may insufﬁciently represent the construct of personality pathology, which
might be better understood dimensionally (Leibing, Jamrozinski, Vormfelde, Stahl, &
Doering, 2008; Morey et al., 2007; Widiger & Trull, 2007). Another problematic aspect
of the current DSM—IV is that the categorical approach may fail to address personality

attributes and psychopathology that are clinically relevant but not severe enough to result

10

in Axis II diagnosis. This problem would be better addressed with a dimensional
approach to understanding personality pathology. Westen and Arkowitz-Westen (1998)
found that of a sample of 714 patients who were being treated for personality problems
(deﬁned as “enduring maladaptive patterns of thought, feeling, motivation, and
behavior”), only 34% actually met criteria for an actual PD, as outlined in the current
DSM-IV. These problematic aspects with the current categorical approach have led to the
investigation of dimensional approaches to assessing personality pathology in clinical
settings.
Dimensional Approach es

The Five Factor Model. Originally developed to assess normative personality, the
Five Factor Model (FFM) of personality has recently been utilized to assess personality
pathology (Samuel & Widiger, 2006; Widiger & Trull, 2007). Such research suggests
that the FFM and its facets would provide a dimensional approach to assessing
personality pathology that would account for differences across PDs as well as reasons
that the current PDs show high comorbidity (Lynam & Widiger, 2001). The ﬁve factors,
including Extraversion, Agreeableness, Conscientiousness, Neuroticism, and Openness to
new experiences, were derived from a lexical analysis without regard to theory or
etiology. Some additional research has applied the F F M to understanding adolescent PDs
with results indicating that the presence of PBS was associated with increased levels of
Neuroticism and decreased levels of Agreeableness, Conscientiousness, Extraversion,
and Openness (De Clercq & De Fruyt, 2003).

While the F FM has been identiﬁed as a potentially useful method of personality

assessment in clinical settings, others have suggested that FFM alone may not be

11

sufﬁcient in itself for understanding personality in such samples (Laverdiere et al., 2007;
Morey et al., 2007). For example, Laverdiére and colleagues (2007) suggest that trait
approaches such as the FFM, and psychodynamic personality organization approaches
such as that outlined by Kernberg, both make independent contributions to understanding
mental health, and are in fact, interrelated. Morey and colleagues (2007) found that while
the FFM provided information about stable personality characteristics, it may not provide
adequate information about dysfunctional and maladaptive behaviors and compensatory
strategies that are better represented in the current DSM-IV PD symptoms. Research
from these studies is consistent with the ﬁndings of Shedler and Westen (2004) who
found that the FF M sometimes did not always provide the nuanced view that may be
needed for working within clinical populations (Shedler & Westen, 2004). They
demonstrated ways in which the FFM groups together clinical phenomena that may in
fact be discrete clinical constructs (e.g., dysphoria and emotional dysregulation are both
represented by Neuroticism in clinical applications of the F F M). In addition, they found
that the FFM failed to account for aspects of personality that are frequently assessed in
clinical settings (e. g., thought disorder, sexual conﬂicts). Finally, several recent studies,
found that clinicians had difﬁculty using the FF M trait approach in clinical practice and
showed preference for a prototype matching approach (including one based on the
SWAP) (Rottman, Ahn, Sanislow, & Kim, 2009; Spitzer, First, Shedler, Westen, &
Skodol, 2008; Westen, Shedler, & Bradley, 2006). Prototype matching approaches (also
dimensional) have clinicians rate how closely a patient matches a description of the

“ideal” form of a syndrome. Overall, the FFM, has become increasingly recognized as

12

personality assessment tool, however, concerns about the measure’s ability to fully
capture the intricacies of personality and personality pathology, are still being evaluated.

The Shedler Westen Assessment Procedure (SWAP). Another dimensional
approach to assessing both personality and personality pathology that was derived from
work with clinical populations as well as empirical research is the Shedler Westen
Assessment Procedure (SWAP). This measure was selected for use in the present
research, because it was designed to utilize clinical experience and expertise when
assessing patient personality. This method of assessment relies on a Q-sort procedure that
is completed by a clinician or clinically trained interviewer using the Clinical Diagnostic
Interview (Westen & Muderrisoglu, 2003). The advantages of using clinicians as
informants include the ability to assess both explicitly and implicitly expressed
information and the assessment of information that may not readily accessible to a patient
completing self-report questionnaire. For example, some research suggests that self-
reports are better at predicting internalizing outcomes, while informant reports are better
predictors of externalizing outcomes or socially undesirable behaviors (Clifton,
Turkheimer, & Oltrnanns, 2005; Oltrnanns, F eidler, & Turkheimer, 2004).

Westen and Shedler (2007) utilized SWAP data in multiple ways to dimensionally
assess personality both in terms of syndromes and traits. A syndromal approach means
that personality can be assessed in terms of a constellation of interrelated characteristics.
This is consistent with the DSM-IV, which views personality pathology as made up of
interdependent features. However, using a trait approach, the SWAP can also be used to
assess separate characteristics (traits) that represent discrete aspects of personality (such

as that found in the FFM). Most relevant to this study, the SWAP can also be used in

13

person-centered analyses to identify personality subtypes of certain psychological
phenomena, consistent with a dimensional syndromal approach (i.e., one in which the
patient is assessed for degree of match to a prototype of the syndrome, and given a
dimensional score denoting degree of match).

Criticisms of the SWAP include issues related to the Q-Sort methodology such as
the use of a ﬁxed distribution and a lack of information regarding temporal stability
(Wood, Nezworski, Garb, & Koren, 2007). Westen and Shedler (2007) state that the
advantage of a ﬁxed distribution is that it prevents patients who have different levels
(e.g., mild and severe) of the same disorder from ending up with the same proﬁle. In
terms of temporal stability data, recent test-retest data using a 4-6 month interval found a
reliability coefﬁcient of .85, suggesting that this unlikely to be a valid criticism (Westen,
Waller, Blagov, Shedler, & Bradley, 2007). Wood and colleagues (2007) also note that
studies supporting the validity of the SWAP have generally obtained information all ﬁom
a single reporter (e. g., the treating clinician). While this was true of most of the studies
using the SWAP, more recent studies have used multiple informants (typically self-report
and treating clinician) to further establish the validity of the SWAP (Bradley, Hilsenroth,
Guarnaccia, & Westen, 2007; Westen et al., 2007). Finally, Mullins-Sweatt and Widiger
(2007) also propose that the aspects of personality that are independent of the FFM may
refer to clinical symptomatology rather than personality. Perhaps this refers to the fact
that the SWAP items include personality functions (e.g., how a patient regulates
emotions, etc) rather than only personality descriptors (Westen & Shedler, 2007).

However, this broader view of personality may be essential in clinical settings.

14

Overall, current research suggests that personality may be better represented in
clinical settings through the use of dimensional assessment measures. A number of
dimensional approaches are currently under development, two of which are described
here. In the current study, the SWAP will be utilized because of several potential
strengths that may provide a nuanced view of personality in the individuals with histories
of attachment disruptions. These include personality assessment that results in
dimensional scores, the possibility of creating dimensional syndromal descriptions or
prototypes, and the reliance on data aggregated from clinically sophisticated informants
that does not presuppose the validity of patient self-reports.

Personality Pathology in Adolescence

One unique aspect of the current research was the consideration of personality
subtypes of individuals with traumatic separations in both adult and adolescent samples.
The importance of considering adolescent personality was to provide continuity across
development in the study of attachment disruptions. Most studies related to attachment
focus on early childhood or infancy (using the Strange Situation) or adulthood (using the
AAI). However, given the extant research on temperament and IWMs, it was likely that
personality and personality pathology begin taking shape in the years prior to adulthood.

The DSM-IV indicates that PDs are very unusual in adolescent patients, and, if
present, would likely persist into adulthood. In order to diagnose adolescent PDs, the
symptoms must be present for at least one year, and not attributable to the developmental
stage. However, recent research has demonstrated that personality pathology is highly
prevalent in adolescent samples (Cohen, Crawford, Johnson, & Kasen, 2005; Grilo et al.,

1998; Westen, Dutra, & Shedler, 2005). Traditionally, adolescence is viewed as a time of

15

“storm and stress,” (Amett, 1999; Hall, 1904), leaving some to suggest it may be a
developmentally inappropriate time in which to diagnose personality pathology.
However, others argue that adolescents show similar levels of affective lability and
dysregulation when compared to adults (Baird, Veague, & Rabbitt, 2005).

There is consensus regarding concurrent validity and similarities between the
presentations of adolescent personality pathology with that of adult personality
pathology. Levy et al. (1999) found strong concurrent validity with adolescent
personality pathology relating to impairment on a range of clinical and global assessment
of functioning scales. In addition to concurrent validity, adolescent personality pathology
occurs at a relatively equal rate to adult personality pathology among psychiatric
inpatients (Grilo et al., 1998). Durrett and Westen (2005), using an exploratory factor
analysis, found that the structure of personality pathology among adolescents was similar
to that of adults.

The current study sought to establish personality subtypes in adolescent and adult
samples both of whom had experienced traumatic caregiver separations, to determine
whether similar subtypes emerge at the two developmental stages. While this study did
not longitudinally follow individuals from adolescence into adulthood, it did yield a
cross-sectional portrait of the differences and similarities between adult and adolescent
personality presentations within clinical settings.

Attachment and Personality Pathology

Some research has explored the relationship of attachment strategies to outcomes

of personality pathology in both adult and adolescent samples. While attachment

strategies are not entirely contingent on experiences of separation and loss, they are a

16

reﬂection of the accessibility, reliability, and quality of care in an individual’s early
caregiving environments (Ainsworth, 1969). Using the AAI in a sample of adolescents,
Kobak and Sceery (1988) found that secure attachment was associated with ego-
resilience and the ability to regulate emotions, preoccupied attachment was related to
higher levels of anxiety, and dismissing attachment was related to increased levels of
hostility and a maladaptive self-reliant style. Other research using clinician reports and
self report measures has found that in adolescent samples, avoidant attachment styles are
most related to cluster A PDs (Crawford et al., 2006; Nakash-Eisikovits et al., 2002).
Anxious attachment was positively associated in one study with cluster A and C PDs
(Crawford et al., 2006), while in another study anxious attachment was more speciﬁcally
associated with PDs related to neediness and dependency (e. g., Borderline, Histrionic,
and Dependent PD) (Nakash-Eisikovits et al., 2002). Interestingly, Nakash-Eisikovits et
a1. (2002) also found a negative correlation between secure attachment in adolescents and
all types of DSM-IV PD diagnoses. After controlling for gender and PD diagnosis,
Westen et al. (2006) found that certain types of PDs in adolescents remained signiﬁcantly
associated with certain attachment strategies. For example, Borderline PD was associated
with both preoccupied and disorganized attachment, and Schizoid PD! was associated
with dismissing attachment. These studies all relied on a single reporter and, with the
exception of Kobak et al., did not use the AAI, which is the standard narrative assessment
measure of adult attachment.

Within adult samples, attachment classiﬁcations also relate to certain patterns of

personality pathology. Using a self-report measure of attachment, Crawford and

colleagues (2006) found that when co-occurring PD symptoms were controlled for,

17

Cluster A PBS were associated with high attachment avoidance (and low attachment
anxiety), while both Clusters B and C showed the opposite pattern. Interestingly, Clusters
B and C were differentiated by interpersonal aggression scale (similar to low
agreeableness in the FF M), such that Cluster B was associated with elevated aggression,
while Cluster C showed low interpersonal aggression. Some of these results are similar to
that of Westen and colleagues (2006), who, using a clinician report measure, found that
after controlling for gender and other PDs, preoccupied attachment was associated with
Borderline, Histrionic PD, and Dependent PD. However, Westen et a1 (2006) also found
that disorganized attachment (which was not included in Crawford’s scale) was
associated with Borderline PD and Paranoid PD, and dismissing attachment was
associated with Narcissistic PD and Schizoid PD. Differences across studies may reﬂect
the measure of assessment (i.e., they use of different attachment scales) and the different
types of reporters (i.e., clinician vs. self-report). Interestingly, both studies make note that
avoidant attachment is not related to Avoidant PD. Crawford et al. suggest, that although
individuals with Avoidant PD have difﬁculty forming relationships, unlike individuals
with avoidant attachment, they tend to hold on to the few relationships that they do have
in a clingy and perhaps preoccupied way.

The adolescent and adult research assessing personality pathology and attachment
here reviewed focused primarily at the correlations certain DSM PBS and attachment
strategies. The current study proposes to extend this past research in a number of ways.
First, rather than considering the association between attachment “states of mind” and
DSM PD diagnoses, the current study instead identiﬁes personality subtypes of

individuals who have had a traumatic attachment experience (i.e., the traumatic

18

separation from an attachment ﬁgure). Personality can thus be assessed more broadly,
and can be representative of subtypes of personality that are more associated with the
common experience of a traumatic separation. Next, the current study did not intend to
assess attachment states of mind. Instead, this study focused on a particular type of
environmental event of signiﬁcance to attachment (attachment disruption) and then set
out to identify personality styles in individuals who have experienced this type of
attachment disruption.
Assessing Personality Subtypes

The wide range of outcomes found among individuals with traumatic childhood
separations suggests the need for assessing whether these individuals may be best
understood as belonging to personality subtypes. The heterogeneous presentation of such
individuals is evidenced in a number of ways.

First, attachment experiences lead to speciﬁc types of IWMs, which are central to
the development of relationships, affect regulation, self-esteem, etc. The experience of a
traumatic separation will have consequences not only for IWMs but also for the entirety
of personality development. In addition, the experience of a traumatic separation for the
individual with an ambivalent attachment strategy may differ ﬁ'om those with an
avoidant, disorganized, or secure strategy. Therefore, the distinct IWMs may be
inﬂuential in the outcomes of various personality proﬁles.

Next, attachment disruptions are associated with a wide range of Axis I and Axis
II psychopathology, as well as dysregulation of the HPA axis. These outcomes do not
represent a single proﬁle that can easily be recognized and treated within clinical settings.

A person-centered assessment of personality proﬁles identiﬁes whether this wide range

19

of clinical phenomena, that currently provides a non-descript conglomerate of symptoms
and features, may actually be better understood as prototypes of individuals who share
the experience of a traumatic separation, yet differ on variables of Axis I and II
psychopathology, developmental history variables, and even family history variables. The
Q-sort analysis provides opportunity for a person centered approach because it identiﬁes
different sub-groups of people that have similar personality proﬁles, while a traditional
factor analysis, a variable-centered approach, would identify groups of items that are
indicative of certain factors. Person-centered analyses attempt to study individuals as
indivisible units, rather than separating variables and studying them without regard to
their original context (Bergman, von Eye, & Magnusson, 2006).

Finally, the signiﬁcance of assessing personality subtypes embraces the concept
of multifmality, which is central to the study of developmental psychopathology. In this
case, multifmality suggests the possibility that the experience of a traumatic separation
from a caregiver can lead to a number of different developmental trajectories, based on
both the individual’s biological, psychological, and social resources. The concept of
multifmality helps explain why individuals with childhood traumatic separations may
belong may have a wide range of personality pathology, as well as a resilient personality
structure.

Aims of the Current Study

The goals of this research were threefold. First was to provide a comprehensive
portrait of the personality characteristics (pathological and non-pathological) of both

adults and adolescents with histories of traumatic separations from childhood attachment

ﬁgures, including patterns of Axis II psychopathology. Second was to discover whether

20

clinically and empirically meaningful subtypes of these individuals could be identiﬁed.
Given that attachment disruptions or traumatic separations from caregivers are associated
with a range of outcomes in the areas of biological, psychological, and social functioning,
the current study will seek to organize these outcomes according to personality subtypes
using a personality pathology Q-sort and a cluster-analytic procedure widely used with
Q-sort data, Q-factor analysis. It was expected that some core similar personality
subtypes would emerge in the adolescent and adult samples, although exact
correspondence was unlikely given the developmental ﬂuidity of adolescence. The ﬁrst
two goals were addressed in studies 1 and 2.

The third goal (addressed in study 3) was to provide initial validity data for the
subtypes that emerge in both samples, using criteria such as those outlined by Robins and
Guze (1970) to assess the validity of any taxonomic distinctions. Speciﬁc hypotheses
regarding DSM psychopathology as well as developmental and family histories related to
each subtype were developed, based on theoretical and empirical literature. These
hypotheses were developed following the identiﬁcation of the subtypes but prior to
examining their external correlates. Thus, the subtypes were identiﬁed through
exploratory analyses, but the hypotheses were generated blind to the data associating
subtypes and criterion variables.

Overview of the Methods

The studies used data collected from two NIMH-funded projects on the nature and
classiﬁcation of adolescent and adult personality pathology. The present author actively
participated in and oversaw many aspects of the data collection for both projects.

Personality pathology was broadly deﬁned in both projects in order to include the current

21

conceptualization of Axis II by the DSM-IV, as well as a much wider range of sub-
threshold personality that may be less severe, or fail to ﬁt into one of the current
diagnostic categories. Clinicians were never asked to describe a patient with a speciﬁc
Axis II PD. In the ﬁrst study, 950 doctoral level clinicians described one of their
adolescent patients (age 13-17), randomly selected, using a battery of psychometric
instruments (see description below). Of these clinicians, 236 described a patient who they
reported to have experienced a traumatic separation between the ages of 1-16. In the
second study, 1201 doctoral level clinicians used a similar psychometric battery to
describe one of their adult patients (age 18 and over), again randomly selected. Of these
clinicians, 201 described an adult patient who they had strong reason to believe had
experienced a traumatic separation between the ages of 1-16. Clinicians in both studies
were directed to classify events such as childhood separations as absent unless they felt
certain, based on data from the patient or collateral data, that the patient had actually
experienced the event. This was done because the data not included are likely to include
many false negatives when clinicians lacked enough knowledge of the patient’s history
but few false positives among patients included in this study. Neither study selected for
patients with traumatic separations; thus, the study is not vulnerable to biases in subject
ascertainment or likely clinician biases based on a single developmental history variable,
given that they provided data on thousands of variables, of which separations in
childhood were just one. In both studies clinicians completed a personality Q-sort and
completed measures of psychopathology (including DSM-IV Axis I and Axis II

diagnoses), adaptive functioning, and developmental history.

22

Study 1: Identifying Personality Subtypes of Adolescents with Histories of
Traumatic Separations from Attachment Figures
Method
Participants
Adolescent data were collected using a practice network approach to taxonomy in
which clinicians were asked to describe a current patient (see Morey, 1988; Shedler &
Westen, 2007; Westen & Chang, 2000; Westen & Harnden-Fischer, 2001; Westen &
Shedler, 1999a, 1999b, 2000; Wilkinson-Ryan & Westen, 2000). A random national
sample of psychiatrists and psychologists with at least ﬁve years post-licensure or post-
residency was obtained from the membership rosters of the American Academy of Child
and Adolescent Psychiatry and the American Psychological Association. Other research
describes the rationale for using clinicians as informants in basic science research (see
Dutra, Campbell, & Westen, 2004; Westen & Shedler, 1999a, 1999b; Westen &
Weinberger, 2003). The advantage of this method is that clinicians are experienced
observers who are able to make inferences and recognize subtle distinctions of
psychopathology based on knowledge of what is considered normative. Unlike self-report
measures and observation reports by signiﬁcant others, clinician-report instruments are
less vulnerable to defensive and self-presentational biases.
Procedures
Clinicians were sent letters inviting them to participate in an adolescent

personality pathology study. Of those contacted, 950 clinicians, one-third of the total
sample, participated in the study. These clinicians returned postcards indicating the age,

race, and gender of their current adolescent patients. In order to obtain a representative

23

sample, gender, age, and race were used to stratify. There was an attempt to have an even
distribution of males and females between the ages of 13- 1 8 and to have a racial
distribution consistent with the US. census. The only exclusion criteria were chronic
psychosis and mental retardation. In the second wave of data collection, there was over-
sampling for ethnic and racial minority patients because clinicians described a low
number of such patients during the ﬁrst wave of data collection.

The clinicians in this study were asked to provide data on a current adolescent
patient who was in treatment for “enduring maladaptive patterns of thought, feeling,
motivation, or behavior—that is personality.” To ensure a random sample, the clinicians
were asked to describe “the last patient you saw last week before completing this form
who meets study criteria.” It was requested that clinicians describe a patient whose
personality they knew, with a guideline of 2 6 clinical contact hours but 5 2 years (to
minimize personality change that may have occurred over the course of treatment).
Clinicians were not asked to describe a patient with a particular diagnosis, nor did
patients need to meet criteria for a PD. The clinicians were also asked to disregard the
caveats in the DSM regarding the application of Axis II psychopathology to adolescent
populations. Instead, it was emphasized that the adolescent patient only needed to display
problematic personality characteristics, as deﬁned above.

Each clinician in the study described just one patient so that rater dependence
variance would be minimized. Patient conﬁdentiality was not compromised because no
identifying information was collected. Clinicians completed a number of questionnaires
and a Q-sort measure using only the information from their interactions with their patient.

Measures could be completed either through a mail packet that could be returned in a

24

provided postage-paid envelope, or alternatively could be completed using a secure web-
based data submission program (www.psychsystems.net). Clinicians received a $200
honorarium for their participation, which took approximately two hours.
Measures

Clinicians who participated in the current study completed a core battery of
questionnaires related to their patient’s demographics, personality, psychopathology,
developmental history, and relationships. However, only the measures relevant to the
current study are described below.

Shedler- Westen Assessment Procedure ZOO-item Q-sort for Adolescents (SWAP-
II-A). This Q-sort instrument assesses adolescent personality by relying on the skills of an
experienced clinician who has observed a patient over an extended period of time, or who
has administered an extensive, systematic, narrative interview to the adolescent and his or
her parents (see, e. g., Westen & Muderrisoglu, 2003). Clinicians sort (rank-order) 200
statements describing adolescent personality characteristics into eight categories based on
applicability to the patient, from those that are not descriptive (assigned a value of 0) to
those which are highly descriptive (assigned a value of 7). Following the suggestion by
Block (1978; 2008), the SWAP-II-A items were written in “standard language,” in this
case, the kind of language experienced clinicians would use to describe a patient but
without any use of jargon. This allowed for the collection of observational data ﬁ'om
clinicians representing diverse theoretical backgrounds.

The SWAP-II-A is an adaptation of its progenitor the SWAP-200, a Q-Sort
designed for assessing adult personality pathology. Westen and Shedler (2007) describe

in great detail the process used to develop the SWAP item sets. SWAP Item content is

25

intended to reﬂect Axis II criteria from the DSM HI and IV, Axis I criteria associated
with personality disturbance (e. g., anxiety), both clinical and research literature on PDs,
and research on child and adolescent psychopathology and personality. In addition,
SWAP items reﬂect normal personality traits, psychological health (Block, 1978;
Livesley, 1995; McCrae & Costa, 1997) and a model of functional diagnosis describing
the range of personality functions used in case formulation (Westen, 1998). Finally, the
items were developed using videotaped clinical interviews, the clinical experience of both
the investigators, and through gathering feedback ﬁom over 1000 experienced clinicians.
The adapted adolescent version was created with additional consultation with senior
adolescent clinicians and through review of adolescent theoretical literature and empirical
research. Research using a previous version of the instrument, the SWAP-200-A,
provided support for the SWAP-II-A as an instrument for assessing personality pathology
in adolescents (see Westen, Shedler, Durrett, Glass, & Martens, 2003). In this earlier
study, dimensional PD scores created using the SWAP-200-A correlated in expected and
meaningful ways with alternative methods of assessing Axis 11, multiple measures of
adaptive functioning (e. g., school and peer functioning; history of hospitalizations,
suicide attempts, and arrests); and with Child Behavior Checklist scores. For example,
using SWAP dimensions for each PD, Borderline PD positively correlated with history of
suicide attempts (r=.46) and Schizotypal PD was negatively correlated with a scale of
peer functioning (r=-.65).

Initial evidence of validity, reliability, and utility of the SWAP-II and [LA have
also been shown in taxonomic research (Westen & Harnden-Fischer, 2001; Westen &

Shedler, 1999a, 1999b, 2000). Using the SWAP, interrater reliability has been established

26

between a treating clinician and independent rater with the median correlation on SWAP
dimensional personality traits being .82. Bradley and colleagues (2007) have found
moderate correlations between self-report PD diagnoses made with the Personality
Assessment Instrument and clinician diagnoses made with the SWAP for the same
disorder (e.g., Borderline r=.3 l; Antisocial r=.35).

Clinical Data Form for Adolescent (CDF-A). The CDF-A is the adolescent version
of the adult CDF which assesses a range of patient variables including demographics,
diagnoses, and etiology (e.g., Westen & Shedler, 1999a; Westen et al., 2003). The ﬁrst
set of questions provides information about the treating clinician including their age, sex,
treatment setting, discipline, and theoretical orientation. The remainder of the CDF-A
asks questions regarding the patient, including basic demographics, diagnostic features,
adaptive functioning, and family and developmental history. Clinicians rate the patient’s
adaptive functioning using indices such as school functioning and peer relationships.
Further objective information, such as history of arrests, traumatic caregiver separations,
psychiatric hospitalizations, and suicide attempts are also obtained. Clinician’s ratings of
adaptive functioning variables are highly correlated with the same data obtained through
independent interview, thus demonstrating interrater reliability and validity (Hilsenroth et
al., 2000; Westen, Muderrisoglu, Fowler, Shedler, & Koren, 1997). The next section of
the CDF-A assesses family history of psychiatric disorders and developmental history
variables with potential relevance to etiology including history of physical and sexual
abuse, and family stability. Clinicians working with adolescents typically have this
information from both the patient and collateral sources such as parents or teachers.

Previous research indicates that clinicians’ ratings of developmental and family history

27

variables predict criterion variables that are theoretically relevant (e. g., Dutra et al., 2004;
Nakash, Dutra, & Westen, 2002). For example, Dutra et a1. (2004) found that CDF
adaptive functioning scales correlated in expected ways with CBCL scales (e.g., as
expected school ﬁmctioning was signiﬁcantly negatively correlated with the CBCL
subscales of attention problems (r=-.51), delinquent behavior (r=-.50), social problems
(r=-.27) and aggressive behavior (r=—.48)). The CDF ratings of the patient’s relationship
with their parent also correlate strongly with scores on a clinician-report Parental
Bonding Inventory and have a similar factor structure as that found using the self-report
version of the measure (PBI; Parker, Tupling, & Brown, 1979; Russ, Heim, & Westen,
2003)

Axis 11 Checklist: The Axis II checklist is a randomly ordered checklist of all the
criteria for the DSM-IV PD diagnoses that was completed by each clinician in regards to
their patient. The measure is used to create both categorical and dimensional DSM-IV PD
diagnoses. To create categorical diagnoses, the DSM-IV decision rules were applied to
determine whether the disorder was either present or absent. Summing the number of
endorsed symptoms for each disorder created dimensional scores. This method of
assessing Axis II psychopathology produces patterns of comorbidity similar to those that
are found using structured clinical interviews (Westen et al., 2003).

Results
The aim of the Study 1 was to identify personality subtypes of adolescents with
tramnatic caregiver separations. Initial exploratory analyses were completed in order to
describe the adolescent patients and identify the existing personality subtypes using a Q-

factor analysis. The initial results and subtypes are described below.

28

Characteristics of Participating Clinicians in the Overall Sample W=95 0)

Of the 950 clinicians participating in the larger study, 57.3% were male and 71.6%
were psychologists. These clinicians represented a range of theoretical orientations
including 3.4% biological, 20.5% cognitive-behavioral, 18.7% psychodynamic, 52.1%
eclectic, and 5.3% other. On average, the clinicians in the overall study were highly
experienced with 18.49 years (SD=8.63) post-residency or post-licensure. The
participating clinicians endorsed working in a range of settings including: 80.6% private
practice, 26.1% clinic or outpatient hospital setting, 10.6% school, 13.2% inpatient or
partial program setting, 8.7% residential facility, 15.9% forensic or other setting.
Clinicians often worked in more than one setting. Finally, the clinicians worked with
their identiﬁed patient for a mean of 12.36 months (SD=10.11) prior to completing the
questionnaire for this study.

Characteristics of the Adolescent Patients in the Overall Sample (N=95 0)

The overall sample of 950 adolescent patients (50.7% female) was on average
15.57 years old (SD= 1.60, range 13-18). These adolescents were 78.7% Caucasian, 7.8%
Aﬁican American, 7.2% Hispanic, 2.6% Asian, and 3.7% biracial or other. The
adolescents ranged in their socioeconomic status, with majority being middle class
(40.7%) or upper-middle class (28.1%). The remaining sample was described as poor
(5.9%), working class (19.2%), and upper class (6%).
Characteristics of Clinicians Describing Adolescent Patients with Histories of
Traumatic Separations

Of the 950 participating clinicians, 236 described an adolescent with a history of

traumatic separation(s) from attachment ﬁgures prior to the age of 16. Clinicians

29

identiﬁed whether to their knowledge the patient experienced any “lengthy traumatic
separations from primary caregiver for more than 6 weeks.” Separate questions assessed
separations variables such as duration and frequency of separations and separations
resulting from divorce or parental death. (Divorces did not automatically constitute
traumatic separations; most patients with a positive history for divorce were not also
coded positive for separations.) Clinicians (61.1% male, 66.8% psychologists) who
described an adolescent with a traumatic caregiver separation were similar to the overall
sample in terms of theoretical orientation: 5.9% biological, 20.8% cognitive behavioral,
18.2% psychodynamic, 49.2% eclectic, 5.9% other. On average, these clinicians were
also highly experienced with 18.17 years (SD= 8.47) post-residency or post-licensure.
Finally, the clinicians describing an adolescent patient with a traumatic caregiving
separation knew their patients well (M= 12.48 months, SD=10.83).

Characteristics of Adolescent Patients with Histories of Traumatic Separations
(N=236)

The adolescents with histories of traumatic separations were 49.4% female. Table
1 compares the adolescents with traumatic caregiving separations to the adolescent
patients without traumatic caregiving separations across a number of domains.

As can be seen in Table 1, Aﬁican American and Hispanic adolescents were more
highly represented in the adolescent sample with traumatic separations than the sample of
adolescents without. It is also notable that the sample adolescents with traumatic
caregiving separations showed higher rates of adolescents from lower socioeconomic
groups than the comparison group. In terms of treatment setting, the adolescents with a

history of separations were seen less often in private practice and more often in clinic or

30

hospital outpatient settings and Inpatient setting. They were almost thirteen times more
likely to be seen in a residential facility than the comparison sample. This is not
surprising given that many were no longer living with their parents or had been removed
from their homes. Differences in Axis I functioning are also presented in Table 1.

Differences in personality pathology between the adolescents with and without
traumatic separations were assessed using an aggregated dimensional measure of each
Axis II PD, constructed by standardizing and averaging the number of symptom criteria
met for each disorder and a ﬁve point construct rating scale for how well a given PD
described the patient. Adolescents with traumatic caregiver separations had signiﬁcantly
higher dimensional scores on Paranoid PD (t [944] = -2.53, p = .01); all cluster B PDs,
including Antisocial PD (t [944] = -6.08, p = .001), Borderline PD (t [944] = -4.58, p =
.001), Narcissistic PD (t [944] = -3.03, p = .003), and Histrionic PD, which was
marginally signiﬁcant (t [944] = -1.96, p = .05). Adolescents with traumatic separations
had signiﬁcantly lower rates of Avoidant PD (t [944] = 3.47, p = .001) and Obsessive
Compulsive PD (t [944] = 2.64, p = .008). These are two PDs that tend to be healthier
both in this sample and in others (Hopwood et al., 2006), and may suggest more severity
in the group with separations.
A Composite Portrait of Adolescents with Histories of Traumatic Separations

To obtain a composite portrait of the personalities of adolescents with traumatic
caregiver separations, the SWAP-II-A proﬁles of the 236 adolescents with such
separations were averaged, and items were arranged in order from highest to lowest (i.e.,
most descriptive to least descriptive). Table 2 presents the 18 most descriptive items,

which were selected because they represent the number of items that can be placed in the

31

two “most descriptive” categories of the ﬁxed distribution (piles 6 and 7) of the SWAP-
II-A Q-sort. The mean rankings in Table 2 reﬂect the average score of a particular SWAP
item across all of the participants who experienced separations. The 18 SWAP items
represent the “average” personality of adolescent who has experienced a traumatic
separation. The composite portrait in Table 2 depicts an adolescent who is emotionally
dysregulated, angry, and unhappy. Interpersonal relationships with peers and authority
ﬁgures are a struggle for these adolescents, and they tend to feel like “outsiders” who are
misunderstood. Within relationships they tend towards having unstable representations
and vacillate in their perceptions of others. They are also likely to project their own
negative qualities on to others. These adolescents may also lack insight regarding their
own behavior.

This composite portrait is striking, and provides insight into a broad
conceptualization of the adolescents with traumatic separations. However, it may mask
differences that might relate to more speciﬁc subtypes of such adolescents. For example,
some adolescents may be characteristically emotionally dysregulated, while others may
be angry and impulsive. To consider this possibility, the next part of the exploratory
analyses involved identifying personality subtypes of adolescents with histories of
traumatic caregiver separations.

Q-analysis and Personality Subtypes with Adolescent Personality Constellations.

A Q-factor analysis was applied in order to examine the possibility of clinically
meaningful personality subtypes of adolescents with traumatic caregiver separations. Q-
factor analysis is a statistical procedure for grouping together cases whose proﬁles are

similar; in this study, it identiﬁes adolescent patients who have a similar personality

32

proﬁle across the 200 items. This method has proven useful in the study of normal and
pathological personality, in part because it does not require the assumption of mutually
exclusive types (Block, 1978, 2008; Caspi, 1998; Robins, John, Caspi, Mofﬁtt, &
Stouthamer-Loeber, 1996). Thus, a patient can resemble one or more subtypes
(prototypes) to varying degrees. This results in each subject having a score on every
subtype indicating the extent to which he or she resembles the prototypical group. In
addition, Q factor analysis, like conventional factor analysis, does not assume the
presence of subgroups and therefore can result in unidimensional or multidimensional
constructs. When applied to personality data, a conventional factor analysis identiﬁes
common underlying dimensions (e. g., such as those found in the Five Factor Model); in
contrast, a Q-analysis identiﬁes patients who have similar proﬁles across items and thus
share a core personality style.

Using standard factor-analytic procedures, the data were ﬁrst entered into a
principal components analysis, specifying eigenvalues 2 1 (Kaiser’s criteria). The scree
plot, percent of variance accounted for, and parallel analysis (Horn, 1965; O'Connor,
2000) were used to determine the number of Q-factors to rotate. Q-factor analyses using
Unweighted Least Squares (ULS) with a Promax (oblique) rotation were conducted for 5,
6, and 7 factor solutions. The 6 factor solution yielded 5 coherent personality subgroups,
accounting for 38.08% of the variance (17.92%, 9.17%, 4.80%, 3.40%, 2.80% for each
Q-factor, respectively), although multiple solutions and algorithms were tested to identify
the most robust Q-factors (in this case, retaining 5 of 6 Q-factors from the 6—Q-factor
solution). The median correlation among factors was .05, suggesting that they are not

only distinct but fairly dissimilar. Correlations are presented in Table 3. Based on the

33

items within the factors, the personality subtypes were labeled “psychopathic,”
“internalizing/avoidant,” “impulsive dysregulated,” “resilient,” and “immature
dysregulated.”

Table 4 shows the 18 items that best characterized each subtype. The items with
the highest factor scores on each prototype are arranged in descending order, expressed in
standard deviation units. (In Q-factor analysis, because cases are factored over items,
instead of items over cases, patients receive factor loadings indexing their degree or
match to the construct, and items receive factor scores. Those factors scores reﬂect the
number of standard deviations each item differed from the other items in the Q-sort in
deﬁning the construct, i.e., how central each item was to the construct, where items with
high scores are most central to the construct.) A brief description of each subtype
follows.

Psychopathic. These adolescents are angry, manipulative, impulsive, and
arrogant. They lack empathy, are critical of others, yet feel misunderstood themselves.
They tend to be “deﬁant toward authority ﬁgures” and lack close friendships or
relationships. They show “little or no remorse for harm or injury caused to others,” are
“impervious to consequences,” and they “have little investment in moral values.”

Internalizing/avoidant. These adolescents have feelings of unhappiness,
emptiness, inadequacy, anxiety, and helplessness. They fear rejection and abandonment
and tend to “feel like an outcast or outsider.” They avoid social situations, are self-
conscious, and “tend to feel ashamed or embarrassed.” They are also characterized by

lack of “satisfaction or enjoyment” and the tendency to feel that “life has no meaning.”

34

Impulsive aysregulated. These adolescents have the tendency to engage in a
number of risky behaviors including abusing alcohol or drugs, sexual promiscuity, self-
mutilation, and running away from home. They “tend to act impulsively,” “seek thrills,
novelty, and excitement,” and have emotions that “spiral out of control, leading to
extremes.” Within relationships, they tend to surround themselves with “peers who are
delinquent”; their “relationships tend to be unstable”; they tend to “become attached
quickly or intensely.” Finally, they tend to be unable to soothe themselves without the
help of another person.

Resilient. These adolescents are articulate, assertive, conscientious, and energetic.
They enjoy challenges and gain recognition for accomplishments. At times they have the
tendency to be anxious. Within relationships they are well liked, empathic, capable of
intimacy, and can “recognize alternative viewpoints.” These teenagers may have the
tendency to express anger indirectly or passively (e.g., procrastinate).

Immature dysregulated. These adolescents appear childish for their age and when
upset they become “irrational” and “tend to revert to earlier, less mature ways of coping.
They tend to have emotions “that spiral out of control” and “change rapidly and
unpredictably.” They are prone to intense anger and extreme reactions to slight criticism.
These adolescents have little psychological insight, are needy and dependent, and think in
concrete terms. Within their relationships, they lack social skills, feel misunderstood, and
have difﬁculty making sense of others’ behavior. They fear rejection and abandonment,

and are unable to soothe themselves without the help of another person.

35

Study 2: Identifying Personality Subtypes of Adults with Histories of Traumatic
Separations from Attachment Figures in Childhood
Method

Participants and procedures for Study 2 were almost identical to those in Study 1,
with the exceptions being that clinicians were asked to describe a randomly selected adult
patient and that there was no stratiﬁcation based on age or gender.
Participants

Participants were again a random national sample of psychologists and
psychiatrists with over ﬁve years experience post licensure or residency whose names
were obtained through the membership rosters of the American Psychiatric and American
Psychological Associations. Of the clinicians contacted, over one-third (N=1201)
participated in the study. The clinicians were asked to describe “an adult patient you are
currently treating or evaluating who has enduring pattern of thoughts, feeling, motivation
or behavior—that is, personality problems—that cause distress or dysfunction.” Just as in
Study 1, it was emphasized to clinicians that the patient did not have to meet criteria for
an Axis II PD. It was required that the patient be at least 18 years of age and be well
known to the clinician as indicated by the guideline of Z 6 clinical contact hours but _<_ 2
years. In efforts to minimize selection bias, clinicians were asked to describe the last
patient they saw in the last week in any clinical setting who met study criteria.
Procedure & Measures

The procedures were almost identical to those described in study with the
following exceptions: l) clinicians were asked to describe a randomly selected adult

patient, 2) there was no stratiﬁcation based on age or gender, 3) clinicians used adult

36

versions of the measures described in Study 1 including the SWAP-II, CDF, and Axis 11
Checklist.
Results

The aim of Study 2 was to identify personality subtypes of adults with histories of
tramnatic separations from attachment ﬁgures in childhood. Initial exploratory analyses
were completed in order to provide a description of the adult patients and identify the
personality subtypes using a Q-sort analysis. The initial results and subtypes are
described below.
Characteristics of Participating Clinicians

Of the 1201 clinicians participating in the larger study working with an adult
patient, 54.3% were female and 70.7% were psychologists. These clinicians represented a
range of theoretical orientations including 3.6% biological, 18.1% cognitive-behavioral,
25.7% psychodynamic, 46.3% eclectic, and 6.2% other. On average, the clinicians in the
overall study were highly experienced with 19.80 years (SD=9. 14) post-residency or
post-licensure. The participating clinicians endorsed working in a range of settings
including: 78.8% private practice, 24.7% clinic or out patient hospital setting, 4.9%
school, 14.9% inpatient or partial program setting, 3.8% residential facility, 10.0%
forensic, and 7% in some “other” setting. Clinicians often worked in more than one
setting. Finally, the clinicians worked with their identiﬁed adult patient for a mean of
17.36 months (SD=—20.57) prior to completing the questionnaire for this study.
Characteristics of the Adult Patients in the Overall Sample (N=1201)
The overall sample of 1201 adult patients (53.4% female) was on average 42.29

years old (SD= 12.35). These adults were 82.6% Caucasian, 6.6% African American,

37

6.0% Hispanic, 2.2% Asian, and 2.7% biracial or other. The adults ranged in their
socioeconomic status, with majority being middle class (39.1%) or working class
(27.2%). The remaining adult patients were described as poor (5.8%), upper middle class
(23.8%), and upper class (4.1%). 1
Characteristics of Clinicians Describing Adult Patients with Histories of Traumatic
Separations (N=203)

Of the 1201 participating clinicians, 203 described an adult with a history of a
traumatic separation. Data regarding separations was missing for 10 clinicians. Clinicians
identiﬁed whether to their knowledge there had been “lengthy traumatic separations from
primary caregiver for more than 6 weeks.” Separate questions assessed separations that
were permanent, due to divorce, or parental death. Clinicians (55.5% female, 63.1%
psychologists) who described an adult with a traumatic caregiver separation were similar
to the overall sample in terms of theoretical orientation: 3.0% biological, 17.2% cognitive
behavioral, 21.7% psychodynarrric, 50.2% eclectic, 5.9% other. On average, these
clinicians were also highly experienced with 20.26 years (SD=9.22) post-residency or
post-licensure. Finally, the clinicians describing an adult patient with a traumatic
caregiving separation knew their patients well (M= 17.99 months, SD=24.31).
Characteristics of Adult Patients with Histories of Traumatic Separations (N=203)

The 203 adults with a history of traumatic separations were 52.7% female. Table
5 compares the adults with traumatic separations to the adult patients without traumatic
separations across a number of domains.

In terms of demographics, a similar pattern emerged as in the adolescent sample.

As can be seen from Table 5, African Americans were more highly represented in the

38

adults with traumatic separations than the sample of adults without. It is also notable that
the sample adults with traumatic separations consisted of higher rates of adults were poor
and who had less than a high school education than the comparison group. In terms of
treatment setting, the adults with a history of separations were seen less often in private
practice. Table 5 also presents rates of Axis I psychopathology.

Differences in personality pathology between the adults with and without
traumatic caregiving separations were assessed using the same aggregated dimensional
PD scales as in Study 1, comprised of two variables after standardization: number of
symptom criteria met for the given PD and a ﬁve point construct rating scale. Adults with
traumatic caregiver separations had signiﬁcantly higher rates of Paranoid PD (t [1184] = -
2.53, p = .01); all cluster B PDs, including Antisocial PD (t [1184] = -4.12, p = .001),
Borderline PD (t [1184] = -2.32, p = .02), Narcissistic PD (t [1184] = -3.32, p = .001),
with the exception of Histrionic PD (t [1184] = -.255, p = .80). Unlike in the adolescent
sample, there were no signiﬁcant differences for cluster C PDs.

A Composite Portrait of Adults with Histories of Traumatic Separations

In order to obtain a composite portrait of the personalities of adults with traumatic
caregiver separations, the SWAP-II proﬁles of the 203 adults with such separations were
aggregated, and items were arranged in order from highest to lowest (i.e., most
descriptive to least descriptive). Table 6 presents the 18 most descriptive items, which
were selected because they represent the number of items that can be placed in the two
“most descriptive” categories of the ﬁxed distribution (piles 6 and 7) of the SWAP-II Q-
sort. The 18 SWAP items represent the “average” personality of adult who has

experienced a traumatic caregiving separation.

39

The composite portrait in Table 6 depicts an adult who is unhappy, anxious, and
angry. Interpersonally these individuals fear abandonment, but also tend to feel like
“outsiders” who are misunderstood. Within relationships they tend to be needy or
dependent and unable to tolerate criticism but are themselves critical of others. These
adults also tend to feel helpless, experience feelings of emptiness, and to rtuninate or
dwell on problems. This portrait also indicates, however, that these individuals tend to
have a number of strengths including being articulate, conscientious, and striving to meet
moral and ethical standards.

This composite portrait provides a broad picture of adults with traumatic
separations, but like the adolescent composite, it may mask differences that relate to more
speciﬁc subtypes. For example, some adults may be more hostile and angry while others
may be more emotionally dysregulated. To consider this possibility, the next part of the
exploratory analyses identiﬁed possible personality subtypes of adults with histories of
traumatic caregiver separations.

Q-analysis and Personality Subtypes with Adult Personality Constellations

Just as with the adolescent sample, a Q-factor analysis was applied in order to
examine the possibility of clinically meaningful personality subtypes of adults with
traumatic caregiver separations. Using standard factor-analytic procedures, the data were
entered into a principal components analysis, specifying eigenvalues z 1 (Kaiser’s
criteria), and using the scree plot, percent of variance accounted for, and parallel analysis
(Horn, 1965; O'Connor, 2000) to determine the number of Q-factors to rotate. These
procedures suggested a 4 or 5 factor solution. Q-factor analysis using Unweighted Least

Squares (ULS) with a Promax (oblique) rotation were conducted for 4, 5, and 6 factor

40

solutions. The 6 factor solution yielded 5 coherent personality subgroups, accounting for
39.71% of the variance (17.23%, 11.31%, 5.43%, 3.53%, 2.20% for each Q-factor,
respectively). The median correlation among factors was .05, suggesting that they are not
only distinct but fairly dissimilar. Correlations are presented in Table 7. Based on the
items within the factors, the personality subtypes were labeled “internalizing/avoidant,”
“emotionally dysregulated,” “resilient,” “hostile/paranoid,” and “psychopathic.”

Table 8 shows the 18 items that best characterized each subtype. The items with
the highest factor scores on each prototype are arranged in descending order, expressed in
standard deviation units. (In Q-factor analysis, because cases are factored over items,
instead of items over cases, patients receive factor loadings indexing their degree or
match to the construct, and items receive factor scores.) The factor scores indicate the '
item’s centrality to the construct in relation to the other items in the item set. The
following paragraphs give a brief description of each personality subtype based on the
representative SWAP-II items.

Internalizing/avoidant. These adults are characterized by feelings of inadequacy,
guilt, anxiety, and unhappiness. They tend to be constricted and unassertive, with the
tendency to turn anger against themselves rather than expressing it outwardly. These
adults fear rejection and abandonment and tend to “feel like an outcast or outsider.” They
avoid social situations, are self-conscious, and “tend to feel ashamed or embarrassed.”
Strengths include being conscientious and striving for moral and ethical standards.
However, their standards are often unrealistic, leading to increased self-criticism.

Emotionally dysregulated. Adults in this subtype tend to have emotions “that

spiral out of control,” “change rapidly and unpredictably,” and become irrational when

41

stressed. These adults tend to be angry, unhappy, and impulsive. Within their
relationships, they fear abandonment and have trouble seeing positive and negative
characteristics of individuals simultaneously. Their relationships tend to be unstable and
they tend to become attached too quickly. Finally, they are unable to soothe themselves
without the help of another person.

Resilient. These adults with traumatic caregiver separations tend to be articulate,
conscientious, creative, and insightful. They enjoy challenges and use talents effectively
and productively. Interpersonally, they are able to sustain meaningful relationships, tend
to be well liked, and are comfortable in social situations. These individuals tend to ﬁnd
meaning both in nruturing or mentoring others and also belonging to a greater
community. They also have the tendency to be competitive and controlling.

Hostile/paranoid. Adults with tramnatic caregiver separations within the
hostile/paranoid subtype tend to be self-righteous, angry, arrogant, and unhappy.
Interpersonally, they lack close ﬁiendships, are critical, suspicious, with the tendency to
blame others for their own shortcomings. At the same time, these individuals tend to feel
like outsiders and feel misunderstood and/or mistreated.

Psychopathic. This ﬁnal subtype of adults tends to be deceitful, impulsive, angry,
and manipulative. They lack empathy and have little psychological insight. They take
advantage of others and show little or no remorse for harm that they inﬂict. They tend to
abuse drugs and alcohol and engage in unlawful behavior, but they are “impervious to
consequences.” Their lives tend to be unstable in terms of work and/or living
arrangements that are identity deﬁning. They tend to “con” others, repeatedly convincing

them that they intend on changing (e. g., “This time it is really different”).

42

Study 3. Validating the Identified Personality Subtypes of Adolescents and
Adults with Traumatic Separations

After identifying the personality subtypes of adults and adolescents with histories
of traumatic separations from attachment ﬁgures in childhood, the next study sought to
validate the personality subtypes using criterion variables. A priori hypotheses regarding
associated psychopathology (Axis I and Axis II), developmental history, and family
history variables were developed based on theory and prior empirical data.

The following section reviews the literature that supported speciﬁc hypotheses for
each of the identiﬁed subtypes.

Personality as an Organizational Framework

Internalizing/A voidant Personality Subtype

In both the adult and adolescent samples an intemalizing/avoidant subtype of
individuals with traumatic separations emerged. The DSM-IV characterizes Avoidant PD
as “a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity
to negative evaluations” (p. 721). As mentioned, Avoidant PD is not associated with
avoidant attachment strategies and instead has been more strongly associated with
anxious attachment (Crawford et al., 2007). Meyer and Pilkonis (2005) suggest that the
avoidance of intimate relationships in individuals with Avoidant PD is fueled by
attachment anxiety in which they fear rejection even though they deeply desire
relationships. This is supported by research, which found that individuals with Avoidant
PD remembered their parents as more rejecting (Stravynski, Elie, & Franche, 1989).
Riggs and colleagues (2007) found that Avoidant personality pathology was associated

with a fearful attachment style, deﬁned as having a negative view of both self and other.

43

The individual with this object representational style feels as though not only are others
unavailable to provide care, but the individual himself perceives himself as unworthy of
such care. This generalizes to later relationships, as individuals who experience
attachment disruptions often have difﬁculty forming conﬁding relationships with peers
(O'Connor et al., 1999; Vonia et al., 1998a; Vorria, Rutter, & Pickles, 1998b).

Bowlby (1973) suggested that attachment disruptions cause the child to
experience the sequence of protest, despair, and detachment. Research with non-human
primates may explain the pattern of avoidance and internalizing personality that may
relate in part to traumatic caregiver separation. Following a traumatic separation, most
studies found that over time, protests and cries decreased (Coe, Glass, Wiener, & Levine,
1983; Erickson et al., 2005; Suomi, Mineka, & DeLizio, 1983). Protests may decrease
because of the onset of despair, which may be related to depressive symptomatology
(Coe et al., 1983). Suomi et al. (1983) found that the experience of the separation has
persistent effects, such that compare to controls, monkeys with traumatic caregiver
separations actively avoided contact with their mothers when reunited at a later point and
overall showed less developmentally expected infantile dependency behaviors. This
ﬁnding may generalize to humans since at an early age a child’s representations of the
caregiver are shaped by the ability of the caregiver to meet the child’s needs. It may be an
adaptive, although avoidant strategy, for infants exposed to early separations to become
independent and disconnected from a caregiver. In contrast, infants without separations
may engage in infantile and dependent behaviors longer to ensure a connection with a

stable provider.

44

It was expected that unlike some of the other identiﬁed personality subtypes, the
intemalizing/avoidant personality subtype will be characterized by internalizing features
due to genetic predisposition and the impact of the separation on neurobiological
functioning, speciﬁcally the HPA axis. Kendler et al. (2002) found that maternal
separation led to a prolonged elevated risk for depression. They speculate that separations
may be associated with other environmental risk factors and that results may be mediated
by genetic factors. Relatedly, Heim and Nemeroff (1999) proposed a pathophysiological
model in which the combination of a genetic disposition and an early adverse experience
that occurs during a critical period leads to the expression of a phenotype that has an
increased neurobiological vulnerability to stress. In considering the neurobiological
impact of early adverse experiences, Heim and Nemeroff (1999; 2001) identiﬁed
corticotropin releasing factor in the HPA axis as the mediator between early stressful life
events and anxious and depressive outcomes. Speciﬁcally, they proposed that early stress
leads to persistent sensitization of the Central Nervous System, long-lasting hyperactivity
of the stress response, and resulting difﬁculties in the regulation of stress and emotion
and ultimately higher anxiety.

Overall, it was expected that the intemalizing/avoidant subtype would be
associated with Avoidant personality pathology and internalizing features including
anxiety and depression. These individuals were expected to have a low number of
conﬁdants due to their view of others as unavailable and rejecting and themselves as
unworthy. Finally, given that genetic factors likely contribute to the development of this
proﬁle, it was anticipated that these individuals will have higher rates of anxiety disorders

within their families.

45

Psychopathic Personality Subtype

Within this study a psychopathic personality subtype characterized by empathic
deﬁcits, anger, and manipulative behavior was identiﬁed in both the adult and adolescent
sample. This subtype is consistent with clinical observations of Cleckley (1941) that were
then studied empirically by Hare (1991; 2003). The DSM-IV describes Antisocial PD as
“a pattern of disregard for, and violation of, the rights of others” (American Psychiatric
Association, 2000, p. 685). However, numerous researchers have questioned whether
antisocial features in adults and adolescents may in fact be combination of several
clinical phenomena, one of which may be psychopathy.

Blair (2006) indicates that psychopathy is characterized not only by behavioral
components (impulsive acts and delinquent or criminal activity) common to antisocial
diagnoses, but also to an emotional and interpersonal component characterized by a lack
of empathy and guilt. He views psychopathic aggression to be instrumental, as opposed
to other aggressive behavior, which is reactive to threatening stimuli. This is consistent
with the research of Frick and colleagues (2003) who identiﬁed “callous-unemotional”
(CU) traits (i.e., low emotional reactivity to aversive stimuli and an absence of guilt
regarding their actions) as differentiating to groups of children with Conduct Disorder.
Nigg (2006) summarizes these ﬁndings stating that CU relates to low negative
emotionality, high positive affectivity, and is unrelated to constraint, while Conduct
Disorder or antisocial behaviors (without CU) relate to high negative affect, low
constraint, and low afﬁliation. Others have identiﬁed differences between those who
commit antisocial acts and feel remorse from those who do not feel remorse, perhaps

indicative of a psychopathic subtype of Antisocial personality (Goldstein et al., 2006).

46

Psychopathy is viewed as highly heritable and relatively consistent across the
lifespan (Blair, Peschardt, Budhani, & Pine, 2006; Lynarn, Caspi, Mofﬁtt, Loeber, &
Stouthamer-Loeber, 2007). Wootton and colleagues (1997) found that child Conduct
Disorder without the presence of CU was associated with parenting and environmental
factors, while Conduct Disorder with the presence of the CU was unrelated to ineffective
parenting. This ﬁnding does not rule out the impact of attachment disruptions on the
development of CU in children with Conduct Disorder, because ineffective parenting is
different than loss or separation. In fact, Wootton et a1. excluded children from their
study who had recently faced a separation from their caregiver.

IWMs have generally been studied in relation to a broader Antisocial domain
rather than speciﬁcally to psychopathy. This research suggests that Antisocial
personality pathology reﬂects an unresolved and dismissing state of mind using the AAI
in adult and adolescent samples (Allen, Hauser, & Borman—Spurrell, 1996; Rosenstein &
Horowitz, 1996; Tirnmerman & Emmelkamp, 2006). This is conceptualized as an
deactivation of the attachment system in which the IWM works to reduce distressing
thoughts that may be associated with adverse early child caregiving experiences such as
attachment disruptions (Riggs et al., 2007). Allen and colleagues (1996) also found that
the dismissing and unresolved state of mind on the AAI predicted criminality in a ten-
year follow-up assessment, indicating the persistent effect of the IWM on behavior, even
into young adulthood. Interestingly, the dismissing state of mind particular to the young
adults with criminal behaviors was a speciﬁc subtype called ‘derogation of attachment.’
Theoretically, this may reﬂect deﬁcits in empathy and anger towards the caregiver that

also extend beyond the family to other relationships and other behaviors that show

47

disregard for the rights of others. As this IWM is chronically accessed across the course
of development it becomes incorporated as a more stable aspect of personality (Shaver &
Mikulincer, 2005).

Weinﬁeld et al. (1999) describe the development of empathy as the
complementary process of aggression by saying, “where aggression often reﬂects an
alienation from others, empathy reﬂects an ampliﬁed connectedness, and whereas
aggression reﬂects the breakdown or warping of dyadic regulation, empathy reﬂects
heightened affective coordination.” (p. 78). The necessity of the attachment relationship
for the development of empathy was supported by Kestenbaum and colleagues (1989),
who found that preschool children with avoidant attachment classiﬁcation had
signiﬁcantly lower levels of empathy than children with secure attachment. Lyons-Ruth,
Alpem, and Repacholi (1993) found that children classiﬁed as disorganized on the
Strange Situation were more likely to show hostile aggressive behavior with their peers.
The early experiences of maternal rejection, low parental nurturing and affection are
linked to antisocial behavior in adolescence (Johnson, Cohen, Chen, Kasen, & Brook,
2006; Trentacosta & Shaw, 2008). Johnson et a1. (2006) reported that this ﬁnding
remained even when controlling for parental psychiatric illness and childhood behavior
and emotional difﬁculties. This research lends supports to the idea that aggressive,
unempathic behaviors can result in part from chronic rejection and insensitivity from
caregivers (Weinﬁeld et al., 1999).

In sum, a psychopathic subtype was identiﬁed in the adult and adolescent sample
of individuals with attachment disruptions. It was expected that the psychopathic subtype

would be associated with conduct disorder, Antisocial PD, and with having a low ntunber

48

of close meaningful relationships. It was anticipated that these individuals would be more
likely to have histories of physical abuse than the other subtypes. Because there is
evidence for the high heritability of psychopathy ,it was anticipated that this subtype
would be associated with a family history of criminality in addition to a personal history
of criminal behavior.

Emotionally Dysregulated Subtypes

Within the adult sample, an emotionally dysregulated subtype with many features
of Borderline personality pathology emerged. In the adolescent sample, two emotionally
dysregulated subtypes emerged. The ﬁrst was characterized by impulsive behavior, and
the second was characterized by immaturity in both behavior and ways of relating to
others. Because both of these adolescent subtypes have a core feature of affect
dysregulation, it is likely that they would share features of Borderline personality
pathology while still being distinct from one another.

A number of studies indicate that attachment disruptions are associated with
Borderline personality pathology (Bradley, 1979; Paris, Nowlis, & Brown, 1988; Reich
& Zanarini, 2001; Soloff & Millward, 1983). However, this experience is seen as neither
necessary nor solely sufﬁcient for the development of the disorder (Levy, 2005). For
example, Torgersen et a1. (2000) found evidence for the heritability of BPD in a twin
study, in which monozygotic twins displayed a 35% concordance rate, compared to the
7% concordance rate in dizygotic twins.

The IWMs of individuals who develop Borderline personality pathology have
been described as predominantly unresolved with a preoccupied trauma when measured

by the AAI (Agrawal, Gunderson, Holmes, & Lyons-Ruth, 2004). This is conceptualized

49

as an overactivation of the attachment system (Riggs et al., 2007). The IWM of the
individual with Borderline features is reﬂected in the inability to represent the thoughts
and feelings of others, originating in the early caregiving relationship. The DSM-IV
describes BPD as “a pattern of instability in interpersonal relationships, self-image, and
affects, and marked irnpulsivity” (American Psychiatric Association, 2000, p. 685). The
disorder may be applied to adolescents and children if symptoms have been present for
more than a year, are considered persistent and pervasive, and are not limited to a single
developmental stage.

Borderline personality pathology may be related to the experience of a traumatic
caregiver separation as well as other adverse developmental history variables such as
childhood sexual and physical abuse (Bradley, Jenei, & Westen, 2005; Golier et al., 2003;
Westen, Ludolph, Misle, Rufﬁns, & Block, 1990). However, results have not always
been consistent suggesting that a range of factors contribute to Borderline pathology. One
possibility is that the attachment relationship provides the child with the tools for affect
regulation, a quality that is often dysregulated in Borderline patients. The caregiver
attenuates negative affectivity and reinforces positive affectivity in order to facilitate this
process (Levy, 2005). The experience of the early caregiving relationship leads to the
development of mentalization, the individual’s ability to understand the interpersonal acts
of self and other by reﬂecting on mental states (Fonagy, Gergely, Jurist, & Target, 2002).

In the case of an attachment disruption, a child who is separated from a consistent
and affectively attuned caregiver will struggle to develop the capacity for mentalization.
Fonagy and colleagues (2002) theorize that the absence of parental mirroring leads to

undifferentiated internal affective states, impoverished awareness of emotional states, and

50

the tendency to confuse one’s own thoughts or internal mind states with external reality.
This theory of mentalization is supported by research ﬁnding that maternal inconsistency
(Bezirganian, Cohen, & Brook, 1993), low parental affection and nurtruing (Johnson et
al., 2006), verbal abuse (Johnson et al., 2001), and invalidation (Young & Gunderson,
1995) are all related to Borderline personality pathology in adolescence or adulthood.

Within both of the adolescent dysregulated subtypes there is evidence of
mentalization difﬁculties. The immature dysregulated subtype has difﬁculty
understanding both his own and others’ behaviors. One possibility is that the absence or
unavailability of the caregiver did not lead to the ability to self-regulate or learn how to
interact with others and imagine their minds. This may contribute to the characteristic of
under-developed social skills. Their emotional dysregulation is presented in the context
of needy and childish ways of behaving. This contrasts with the impulsive dysregulated
subtype, which is more characterized by impulsive and delinquent behaviors. Their
mentalization difﬁculties are more in the context of unstable and ﬂuctuating views of self
other such that they quickly attach to others but then have rapidly changing relationships.
They also have a similarly unstable view of the self. The adult emotionally dysregulated
subtype resembles more closely the impulsive dysregulated subtype in terms of
mentalization style, and of the three, most closely resembles Borderline PD. It may be
that the two emotionally dysregulated adolescent subtypes (immature and impulsive) are
indicative of a more complex representation of the ways in which individuals classically
lumped together under a Borderline PD diagnosis may be understood.

Individuals with Borderline PD manage their affective dysregulation with

maladaptive coping mechanisms (e. g., drugs, self-injury) (Bradley & Westen, 2005).

51

Borderline personality pathology is also associated with higher rates of suicidality and
parasuicidal behavior, which has been linked to dysregulated affect (F oote, Smolin, Neft,
& Lipschitz, 2008; Grilo et al., 2007). These types of responses were most evident within
the personality descriptions of the impulsive dysregulated adolescents.

Neuroendocrinal research suggesting that the affective dysregulation seen in
Borderline personality pathology may be related to HPA responses. Lieb and colleagues
(2004) found that adults with BPD showed higher levels of cortisol both at the time of
awakening and over the course of the day. Levy (2005) suggests that when a child is
faced with stressors, secure attachment may moderate the effects of temperament and
protect against elevated cortisol. Higher cortisol levels are linked to increased anxiety,
depression and externalizing behaviors (Gunnar, Morison, Chisholm, & Schuder, 2001;
Heim & Nemeroff, 1999; Heim & Nemeroff, 2001). These may be precursors to the
development of personality pathology related to emotional dysregulation.

In sum, based on the extant research it was anticipated that all of the emotionally
dysregulated individuals with traumatic separations would have higher rates of
Borderline personality pathology, depression, and some features of anxiety and substance
abuse. However, the immature dysregulated adolescents were expected to have less
substance use and lower rates of Borderline PD than the impulsive dysregulated
adolescent subtype. All emotionally dysregulated subtypes were anticipated to have
developmental histories with higher rates of sexual abuse, suicidality, and poor global
functioning. Physical abuse was also expected to be part of the developmental histories of
these individuals. Given that Borderline PD has been found to be heritable, it was

anticipated that individuals with traumatic caregiver separations and emotionally

52

dysregulated presentation will be more likely to have family members who also struggled
with similar dysregulation as indicated by a higher rate of family suicidality.

Within the adolescent sample, the immature dysregulated subtype was expected to
show more social impairment and dependency. Consistent with the research studying to
deﬁcits in mentalization, the immature dysregulated subtype was expected to have a wide
range of problems relating to and understanding the thinking and behavior of others. As a
result these adolescents would likely have fewer conﬁdants than the other subtypes.
When upset, individuals in the immature dysregulated subtype were expected to respond
by affective dysregulation characterized by becoming increasingly more childish (as
opposed to impulsive acting out behavior). The immature dysregulated adolescents were
expected to be less consistent with the prototypical Borderline PD diagnosis and some of
their emotional dysregulation and immature appearance could be associated with the
developmental stage of adolescence.

In contrast, the adolescent impulsive dysregulated subtype was expected to
engage in more impulsive (e. g., substance use, sexual promiscuity, self-harm), delinquent
(e. g., rule breaking), and age inappropriate behavior. From a mentalization perspective,
these adolescents would experience chronic feelings of emptiness and unstable sense of
self due in part to some disruption in the early attachment relationship. These
characteristics are also part of the DSM-IV Borderline personality criteria. As a result,
they have unstable relationships and become to quickly attached to other people who are
similarly unstable. The dysregulation in these adolescents would likely lead to rule-
breaking behaviors associated with high rates of oppositional deﬁant disorder, conduct

disorder, and Antisocial personality pathology. These adolescents were expected to have

53

high rates of attention deﬁcit disorder and substance abuse, which would be associated
with their impulsivity. With regards to their developmental history impulsive
dysregulated adolescents were expected to have high rates of both sexual abuse and
physical abuse. Finally, these individuals were expected to have family histories of
substance abuse and suicidality reﬂecting a likely heritable pattern of irnpulsivity,
dysregulation, and need for external stimulation.

Hostile/Paranoid Subtype

Within the sample of adults with traumatic separations a hostile/paranoid subtype
emerged. The relationship between Paranoid PD features and attachment has been
explored in some of the psychoanalytic theoretical literature as the individual having
experienced the early love object as both needed but also persecutory (Bltun, 1981). The
DSM-IV indicates that individuals with Paranoid PD have a “pervasive mistrust and
suspiciousness of others such that their motives are interpreted as malevolent” (p. 694).
These individuals develop the expectation that they will be mistreated (PDM Task Force,
2006). Interestingly, the interpersonal cues that are threatening to the individual with
paranoid features are often unapparent to others.

There is lirrrited empirical research studying the attachment experiences and
developmental history of individuals with paranoid features. Rankin and colleagues
(2005) found that both remitted and non-remitted paranoid patients reported a history of
low parental care. Similarly, Kinderman and Bentall (1996) found that paranoid patients
were more likely than non-paranoid patients to believe that their parents had negative
views of them. Golier and colleagues (2003) found that individuals with Paranoid PD

were more likely to have experienced physical abuse during childhood than those without

54

Paranoid PD. With regards to attachment classiﬁcations, Westen and colleagues (2006)
found that after controlling for other PDs and gender, Paranoid PD was associated with
incoherent/disorganized attachment in an adult sample but not in an adolescent sample.
Within adolescent samples others have found associations between dismissing or
avoidant attachment (Nakash-Eisikovits et al., 2002; Rosenstein & Horowitz, 1996)
suggesting that such adolescents devalue attachment relationships.

Previous research has found that individuals with Paranoid personality pathology
lack friendships, have difﬁculty understanding others, and often feel victimized (Shedler
& Westen, 2006). With regards to psychopathology, there are reports of high comorbidity
with Antisocial personality. For example, Fonagy and colleagues (1996) found that in an
inpatient sample, two out of three of the individuals with Antisocial PD also met criteria
for Paranoid PD, leading them to make a combined group. In terms of developmental
history, Yang and colleagues (2007) found that Paranoid personality pathology in adults
with histories of being institutionalized was associated with conduct disorder in
childhood.

Based on the extant research, the hostile/paranoid subtype of adults with traumatic
separations was expected to relate not only to Paranoid PD diagnoses but also to
Antisocial PD. Individuals in this subtype were expected to have higher rates of a history
of physical abuse compared with sexual abuse.

Resilient-High Functioning Personality

Within both adult and adolescent samples, a resilient subtype emerged. Many

individuals who experience a traumatic caregiver separation overcome this experience to

become high-functioning adults and adolescents. While separations and loss may lead to

55

increased rates of personality pathology, these are probabilistic, not deterministic
associations. While some individuals have constitutional traits leading to an increased
likelihood of personality pathology, others may have constitutional traits that are
protective in the face of loss. This is consistent with the resilience association in which
temperament protects children from the impact of adverse environmental stimuli and any
associated psychopathology (Shiner & Caspi, 2003). In addition to constitutional traits,
environmental factors can also be protective. Research examining attachment disruptions
suggests that interpersonal relationships both before and after the separation can
inﬂuence developmental pathways in human and non-human primate samples. Reite,
Kaerningk, and Boccia (1989) found that Pig-tail monkeys, who were adopted by a
Sturogate, showed less agitation and depression following a‘separation from their
biological mother. Interestingly, these Pig-tail infants were most able to use the adoptive
mother to regulate their emotions when they had a positive relationship with their initial
caregiver. Similarly, Vorria et al. (1998a) found that emotional and scholastic outcomes
of children living in long-term residential group care were predicted by the situation that
lead to their initial placement in the group home (e.g., abandonment, ﬁnancial
difﬁculties, loss). Children who came from harmonious homes were the highest
functioning. This may represent the IWM serving as a mediator to a resilient outcome in
the developmental pathway. Finally, just as the IWM may serve as mediator leading to
personality pathology it may also protect a person from pathological outcomes, despite
the experience of an attachment disruption. These ﬁndings also illustrate that protective
factors derived ﬁ'om relationships both before and after attachment disruptions may have

lasting effects of personality.

56

Therefore, it was expected that the resilient high-functioning subtype would have
relatively low rates of Axis I and Axis II psychopathology. It was also anticipated that the
developmental histories for these individuals would on average reﬂect low rates of abuse,
low rates of antisocial behavior and suicidality, and families who had relatively lower
rates of psychopathology. These individuals were expected to be the least impacted by a
traumatic caregiver separation due to protective environmental and genetic factors.

Hypotheses Regarding Criterion Variables

Based on the extant theoretical and empirical literature, a priori hypotheses were
made regarding the relationship between the subtypes and the criterion variables (see
Tables 12-15). These hypotheses were focused on the relative ordering of group means
(represented by contrast weights) on various Axis I and H disorders, adaptive functioning,
developmental history, and family history variables. The data were analyzed with both
contrast analyses and correlational analyses (treating the subtypes both categorically and
dimensionally), which produced highly similar results. While results from both analyses
were presented, the focus was on the contrast analyses, which had the capacity to test
highly focused, speciﬁc, directional hypotheses.

The hypotheses regarding the different domains of criterion variables were
presented in numeric form as contrast weights in Tables 12-15. For example, in Table 12,
the contrast weights for adolescent Major Depressive Disorder (MDD) of 0, 2, 2, -6, 2
represent the a priori hypothesis that the two emotionally dysregulated subtypes and the
internalizing/avoidant subtype would have the highest rates of MDD (2), followed by the
psychopathic subtype (0), and then lastly the resilient subtypes (-6). This hypothesis was

developed taking into account research studying outcomes of depression in individuals

57

with traumatic separations related to dysregulation of the HPA axis, seen in both
internalizing and emotionally dysregulated personality research (Heim & Nemeroff,
1999; Heim & Nemeroff, 2001; Lieb et al., 2004).

In contrast, the contrast weights for adolescent Conduct Disorder (CD) of 3, -4, 3,
-3, 1 indicated that the psychopathic and impulsive dysregulated subtypes were expected
to have the highest rates of CD (3), followed by the immature dysregulated subtype (1),
with the resilient (-3) and internalizing subtypes (-4) expected to have the lowest rates.
This hypothesis was supported by data suggesting that antisocial behavior is associated
with both deﬁcits in empathy and impulsivity (Blair et al., 2006; Burt & Donnellan,
2008; Mofﬁtt, 2006).

With regards to an adolescent development history variable (see Table 13), the
contrast weights for childhood sexual abuse of 0, 0, 3, -5, 2 indicated that the impulsive
dysregulated subtype would have the highest rates (3), followed by the immature
dysregulated (2), then the psychopathic and internalizing/avoidant subtypes (0), and lastly
the resilient (-5). This hypothesis reﬂects the research that has established a relationship
between both emotional dysregulation and Borderline PD with childhood sexual abuse
(Bradley, Jenei et al., 2005; Westen et al., 1990).

This same pattern of interpretation may be used to interpret the remaining
hypotheses in Tables 12-15

In the ﬁnal set of analyses, hierarchical linear regression was used to assess the
incremental validity of the subtypes. Here, it was hypothesized that the personality
subtypes would account for a signiﬁcant portion of the variance in global adaptive

functioning after controlling for demographic variables (race, age, gender, and

58

socioeconomic status) and other traumatic events in childhood (e. g., childhood abuse,
witnessing violence). Thus, the goal was to examine whether, within a sample of
adolescents and within a sample of adults with a history of traumatic separations,
personality styles could predict functioning above and beyond other predictors (and
essentially holding constant history of attachment disruptions, since all the subjects
included in this analysis had suffered disrupted attachments).
Method: Participants, Procedures, and Measures

The goal of study 3 was to validate the personality subtypes using both external
criteria and by considering the incremental validity of the subtypes. Participants included
the clinicians who described adolescents and adults with traumatic childhood separations
from attachment ﬁgures in study 1 and study 2. Procedures and Measures were already
described in the preceding studies.

Results

Validating the Personality Subtypes

The goal of these analyses was to provide an initial test of the construct validity of
the personality styles identiﬁed through Q-factor analysis by testing speciﬁc predictions
about patterns of association with criterion variables that should distinguish them
(Andreasen, Endicott, Spitzer, & Winokur, 1977; Westen & Muderrisoglu, 2003). This
study utilized additional data reported by the clinician including Axis I and II
psychopathology, individual history variables (e. g., history of physical abuse), and family
history variables (e.g., substance abuse, criminality). These criteria are similar to those

elaborated by Robins and Guze (1970) for validating diagnostic distinctions, particularly

59

comparing the subtypes on comorbid diagnoses, adaptive functioning, and etiologically
relevant variables.

To test a priori hypotheses, the personality subtypes were treated categorically.
Adults and Adolescents were assigned to the subtype on which they had the highest
factor loading, presuming (1) the loading was _>_ .35, which indicates considerable match
to the diagnostic prototype; and (2) the primarily loading was _>_. 10 higher than any
secondary loading. Thus, patients who did not load highly on any factor or loaded highly

on multiple factors were not included. Using this approach, 159 (67.4%) of the 236

adolescents and 154 (75.9%) of the 203 adults were classiﬁedl. Patients without histories

of separations were also assigned categorically to a subtype using the same method to
rule out the rival hypothesis that these subtypes represent characteristics of a clinical
sample rather than of patients with a history of disrupted attachments.

Table 9 presents the distribution of patients with and without separations across
the subtypes. Most notable was that within both the adult and adolescent samples, higher
percentages of the psychopathic subtype occurred within the samples of individuals with
traumatic separation histories as compared to those without separation histories. Treating
the personality subtypes as continuous variables and using t tests yielded the same pattern
of results. In the adolescent sample, the average factor loadings were signiﬁcantly higher

in the separations group than the non-separations group for the psychopathic (t = -4.43, df

 

1 Of the unassigned adolescents, 46% did not load at .35 or above on any subtype, 14% loaded highly on
both the psychopathic and impulsive dysregulated subtypes, 10% loaded on the psychopathic, impulsive
dysregulated, and immature dysregulated subtypes, 5% loaded on both the impulsive dysregulated and
immature dysregulated and 5% loaded on both the intemalizing/avoidant and immature dysregulated
subtypes. Of the unassigned adults, 39% did not load at .35 or above on any subtype, 16% loaded on both
the intemalizing/avoidant and resilient subtypes, and 34% loaded on the emotionally dysregulated subtype
and at least one other subtype.

60

= 943, p <.001) and impulsive dysregulated dimensions (t = -4.21, df= 943, p <.000), and
signiﬁcantly lower for the intemalizing/avoidant (t = 3.91, df= 943, p <.001) and
resilient (t = 3.77, df= 943, p <.001) dimensions. Within the adult sample these
differences were signiﬁcantly higher in the separations group than the non-separations
group for the emotionally dysregulated (t = -2.40, df= 1189, p =.02), and psychopathic
dimensions (t = -3.89, df= 1189, p <.001), and signiﬁcantly lower than the non-
separations group for the internalizing avoidant dimension (t = 3.33, df= 1189, p =.001).
Demographic Variables by Subtype

Analysis of variance (AN OVA) was used to identify any differences between the
subtypes on age, sex, race, and socioeconomic status. In the adolescent sample, subtypes
differed signiﬁcantly by sex (F (4,154)= 5.70, MSE=.22, p=.000), age (F (4,153)= 4.00,
MSE=2.43, p=.004), socioeconomic status (F (4,153)= 3.39, MSE=1.25, p=.03), but not
by race and ethnicity (F (4,154)= 4.00, MSE=1.06, n. s. ). The same pattern of results was
found in the adult sample [sex (F (4,149)= 8.45, MSE=.21, p=.000), age (F (4,148)=
5.33, MSE=152.54, p=.000), socioeconomic status (F (4,149)= 4.24, MSE=1.11, p=.003),
race and ethnicity (F (4,148)= 2.18, MSE=.83,n.s)]. Tables 10 and 11 present
demographic variables by subtype. Notable gender differences common to both samples
were that psychopathic subtype was substantially male, while the emotionally
dysregulated (or adolescent impulsive dysregulated) was substantially female.

Subtypes were also compared by characteristics of the traumatic separation.
Neither the adolescent or adult subtypes differed signiﬁcantly by age of separation
(Adolescent F (4,154)= .59, MSE=.23, n.s.; Adult, F (4,149)= .72, MSE=.21, ns.) or by

the clinician’s rating of the separation’s traumatic impact on a scale of 1-5 (Adolescent, F

61

(4,153)= .40, MSE=1.15,n.s.; Adult, F (4,148)= 1.03, MSE=1.26, ns.). Means and
standard deviations for these variables are presented in Tables 10 and 11.
Contrast Analyses

Contrast analyses were used to compare the groups on validity criteria and to test
a priori hypotheses. Beneﬁts of using contrast analysis include the maximizing of power
and reducing the likelihood of spurious ﬁndings that occur when running multiple
analyses. In addition, contrast analysis tests highly speciﬁc, focal, one-tailed hypotheses
about the relative ordering of group means instead of more global questions that do not
specify in advance how the groups may differ (Rosenthal, Rosnow, & Rubin, 1999). The
a priori hypotheses for each sample were developed based on the previously reviewed
theoretical and empirical literature and are presented along with the results in Tables 12-
15. Axis I and 11 variables were dummy coded (0/ 1), resulting in means that correspond
to percentages. All remaining variables were dummy coded with the exception of global
adaptive functioning, criminality, and number of conﬁdants, which were continuous
variables. The global adaptive functioning composite variable was created by averaging
the standardized ratings of GAF, level of personality functioning, quality of peer
relationships, and work or school functioning. The early-onset delinquency variable in
the adolescent sample was a composite variable created by averaging the standardized
ratings of arrests, violence, torturing animals, stealing, and ﬁre setting. In contrast, the
adult criminality composite variable was created by averaging the standardized ratings of
the arrests within the past ﬁve years, violent crime committed in the past ﬁve years, and
having been a perpetrator in an adult abusive relationship. Number of conﬁdants was

coded on a 1 to 4 scale (1=none, 2= very few, 3= some, 4= many). Because the subtypes

62

in the adult and adolescent sample signiﬁcantly differed on socioeconomic status, age,
and gender, these variables were controlled for in secondary analyses, which yielded the
same patterns of signiﬁcant results.

The results of the contrasts analyses and corresponding effect sizes are presented

in Tables 12-15. These effect sizes (r) are converted from the t-scores resulting from the

2 . .
contrast analyses . Wrth regard to Axrs I psychopathology, there was support for the

expected associations of Major Depression, Substance Use Disorder, Oppositional
Deﬁant Disorder, and Conduct Disorder. Effect sizes for these analyses ranged from .39-
.65. However, the expected ﬁndings regarding Generalized Anxiety Disorder were not
supported in either sample. While rates of Generalized Anxiety Disorder were relatively
low across all subtypes, it was notable that the resilient subtype seemed to have higher
levels of the disorder than had been anticipated in relation to the other subtypes,
suggesting that anxiety may be one of the residues of disrupted attachment in the resilient
group. In addition, within the adolescent sample, rates of Attention Deﬁcit Hyperactive
Disorder did not differ across subtypes.

With regards to Axis II psychopathology, all hypotheses were supported using
contrast analyses, with corresponding effect sizes ranging from .42-.60. The psychopathic
subtypes had the highest rates of Antisocial PD (adolescent 67%; adult 90%), while the
Adult Emotionally Dysregulated and Adolescent Impulsive Dysregulated had relatively
high rates of both Antisocial PD (adolescent 63%; adult 43%) and Borderline PD
(adolescent 67%; adult 75%). As expected, the Intemalizing/Avoidant subtypes had the

highest rates of Avoidant PD (adolescent 47%; adult 70%). With regards to adult

 

2 The formula for this conversion was: r = ‘l(t2 / [t2+ dﬂ)

63

Paranoid PD, rates were relatively elevated in the Hostile/Paranoid subtype (55%),
Psychopathic Subtype (54%), and the Emotionally Dysregulated subtype (50%).

A priori hypotheses regarding global adaptive functioning and developmental
history were also supported by the ﬁndings (See Tables 13 and 15). The individuals with
high loadings on the resilient subtypes had the highest global adaptive functioning.
Within both the adult and adolescent samples the lowest functioning subtypes were the
psychopathic and emotionally dysregulated (including both the adolescent immature and
impulsive dysregulated subtypes). The subtypes characterized by having the lowest
numbers of conﬁdants were the psychopathic (both adult and adolescent), immature
dysregulated, and hostile/paranoid. However, it is possible that the underlying reason for
the low number of close conﬁdants differs depending of the nature of the subtypes. The
intemalizing/avoidant subtypes had higher numbers of conﬁdants, perhaps in part due to
their higher levels of global adaptive functioning. History of criminal activity was highest
among the psychopathic subtypes, and history of suicide attempts was higher among the
emotionally dysregulated subtypes (adolescent impulsive 75%; adolescent immature
53%, adult 75%). With regards to physical and sexual abuse, rates were elevated across
expected subtypes. It was notable, however, that within the adolescent sample, the
highest rates of physical abuse occurred within the immature dysregulated (59%) and
impulsive dysregulated (50%) subtypes.

Finally, results regarding family history variables were somewhat inconsistent.
Consistent with the Axis I ﬁndings, family history of anxiety disorder did not
differentiate the groups. The adolescent subtypes were differentiated by family history of

criminality and suicidality but not family history of illicit drug use. The adult subtypes

64

were differentiated by family history of criminality and illicit drug use but not by
suicidality.

The contrast analyses treated subtype assignment as a categorical variable.
Results were replicated using correlations to treat the subtypes (or dimensions) as
continuous variables (See Tables 16 and 17). This allowed for each individual with a
traumatic separation to be included in the analyses. A similar pattern of results emerged.
Notable differences will be highlighted here. A difference with regards to Axis I
psychopathology included the absence of a signiﬁcant positive correlation between the
adolescent psychopathic dimension and substance use disorder (r=. 06). In terms of
developmental history variables, there were no signiﬁcant positive correlations between
subtypes and physical abuse history within the adolescent sample. Within the adult
sample, the emotionally dysregulated dimension (r=.45), but not the psychopathic
dimension (r=.11) was signiﬁcantly positively correlated with physical abuse history at
the .05 level. With regards to family history of suicidality, the contrast analyses had
found rates of 94% within the adolescent immature dysregulated subtype. However,
using correlations to treat the subtypes dimensionally there was no signiﬁcant positive
correlation between the immature dysregulated dimension and family history of
suicidality (r=.10).

Incremental Validity of the Traumatic Separation Personality Dimensions

The ﬁnal set of analyses tested the incremental validity of these personality
dimensions in predicting global adaptive functioning while holding constant demographic
variables and a composite childhood trauma variable. The childhood trauma composite

was created by averaging the standardized ratings of presence of childhood physical

65

abuse, childhood sexual abuse, witnessing violence between parents, involvement of state
agencies charged with protection of children, and maternal history of sexual abuse.
Personality dimensions were treated as continuous variables for these analyses. Using
hierarchical multiple regression, demographic variables (age, sex, race, and
socioeconomic status) were included in the ﬁrst step of the model, the childhood trauma
composite variable was included in the second step, and the personality dimensions were
placed in the third step.

As can be seen in Table 18, within the adolescent sample, the demographic
variables and the composite childhood trauma variable together accounted for a
substantial amount of variance in functioning (18%). Of the demographic variables,
socioeconomic status was the main predictor of functioning. However, in step 3 of the
model, the personality dimensions added substantially to prediction, accounting for 36%
more of the variance.

Within the adult sample, a similar pattern of results emerged (See Table 19). Once
again, among the demographic variables, socioeconomic status was the greatest predictor
of functioning. In contrast to the adult model, the childhood trauma composite variable in
step 2 did not predict a signiﬁcant portion of variance over and above the demographic
variables. However, in the step 3 of the model, the personality dimensions once again
added to substantially to the prediction of variance in global adaptive functioning
accounting for an additional 36% of the variance.

General Discussion of the Three Studies
The aim of this research was to identify personality subtypes of adolescents and

adults with traumatic attachment separations (Studies 1 and 2 respectively) using

66

exploratory Q analyses. Study 3 provided initial validity data for the identiﬁed
personality subtypes using contrast analyses, correlational analyses, and hierarchical
linear regression. The initial two studies produced strikingly similar ﬁndings: Both
samples converged on psychopathic, internalizing/avoidant, dysregulated, and resilient
subtypes The sole difference was that the adolescent sample produced two types of
dysregulated patients, one more impulsive and the other more immature, whereas the
adult sample produced a single hostile/paranoid subtype. A review of the empirical
literature suggested that these subtypes are both theoretically sound and clinically
coherent.

The results showed that a composite description of the personalities among these
individuals masks the patterned heterogeneity found in patients with histories of
traumatic separations, which highlights the importance of using personality in clinical
settings to better understand and organize the heterogeneous presentations of individuals
with attachment disruptions. These results were consistent with additional research that
used personality constellations to organize the diverse clinical presentations of people
who share a common traumatic experience (Bradley, Heim, & Westen, 2005).

Adolescent and Adult Traumatic Separation Subtypes
The SWAP items provided a portrait of the prototypical patient from each
subtype. In the adolescent sample, the psychopathic subtype was primarily male, these
youths tended to rebellious, angry, and lacked empathy for others. The
internalizing/avoidant subtype was characterized by depressed mood, low self-esteem,
and feelings of being an “outsider”. The impulsive dysregulated subtype was

substantially female and was characterized by emotions that spiral out of control,

67

unstable relationships, and difﬁculty with self-soothing. Other behaviors for this subtype
included substance abuse and sexual promiscuity. While the immature dysregulated
group was also described as having “emotions that spiral out of control,” these
adolescents tended to be childish and have difﬁculty thinking in complex and insightful
ways about their own mind and the minds of others. Finally the resilient adolescent
subtype provided a portrait of a patient who would be likable, energetic, and articulate,
with the capacity pursue goals and have meaningful relationships.

In the adult sample, many of the same subtypes emerged. The adult psychopathic
subtype had little empathy for others, and was also characterized as manipulative and
impulsive, with the tendency to engage in criminal acts. The internalizing/avoidant adult
subtype was very similar to that found in the adolescent group. The adult emotionally
dysregulated group most closely resembled the adolescent impulsive dysregulated group.
This subtype appeared to be primarily female and have characteristics of emotional
lability, intense anger, and fears of abandonment. Unique to the adult sample was the
hostile/paranoid subtype, which created a portrait of a rigid, critical, and angry individual
who lacks close relationships and is suspicious of others. Finally, the resilient adult
subtype was characterized with many of the same descriptors as those found for the
adolescent resilient subtype.

It should be noted that individuals without separations can also be classiﬁed with
these subtypes, suggesting that the subtypes are unlikely unique to individuals with
traumatic separations. However, it appears that separations may predispose individuals to
certain forms of psychopathology. Speciﬁcally, the psychopathic subtype and the

emotionally dysregulated adult/impulsive dysregulated adolescent subtypes were better

68

able to describe individuals with separations than those without. This would be consistent
with previous attachment research, which has described affect regulation, interpersonal
stability, and lack of empathy and the ability to reﬂect on the perspective of potential
victims as consequences of traumatic attachment disruptions (Bezirganian et al., 1993;
Fonagy, 1999; Fonagy & Bateman, 2008; F onagy et al., 1997; Johnson et al., 2006;
Kemberg & Caligor, 2005). All of these characteristics could be inﬂuenced by
mentalization deﬁcits, which are related, in part, to experiences within the parent-child
relationship (Fonagy et al., 2002).

Interestingly, these two subtypes showed clear sex differences, perhaps indicating
that certain developmental trajectories associated with traumatic separations are more
common to males (psychopathic) and females (emotionally dysregulated). The extant
research regarding sex differences across personality disorders reveals highly
inconsistent results. Some research has found that Borderline personality pathology is
more common in females (Ekselius, Bodlund, von Knorring, Lindstrom, & Kullgren,
1996; Grilo et al., 1996) or that Antisocial personality pathology is more common in
males (Ekselius et al., 1996; Grilo, 2002; Lynarn & Widiger, 2007). However, this is not
the case across all studies (Golomb, Fava, Abraham, & Rosenbaum, 1995). Identifying
personality subtypes that are primarily male or female raises questions about gender
speciﬁc adaptation. In one study, Grilo and colleagues (1996) understood higher rates of
Borderline PD in females and Narcissistic PD in males to be associated with differences
in developmental biases. They suggest that females may be pushed to be more aﬁlliative
and interpersonally connected, while males may be more inﬂuenced to be powerful,

independent, and controlling. If these developmental gender biases were overly utilized

69

following a traumatic attachment disruption, this may explain personality subtypes that

are more male or female speciﬁc. Akhtar (1996) suggests the need not only to study

gender differences in prevalence rates of personality disorders, but also to consider

gender differences in etiology, symptomatology, broader social inﬂuences, and outcomes

related to personality pathology. More research is needed to understand the way

personality development is inﬂuenced by gender following a traumatic separation.
Personality Subtypes and Comorbid Psychopathology: Axis I and II Criterion

Variables

The contrast analyses tested a priori focal hypotheses to provide support for the
taxonomies. As expected, the proﬁles differed by DSM-IV diagnoses. The psychopathic
subtype was associated with Antisocial PD in both the adults and adolescents, and with
Conduct Disorder, and Oppositional Deﬁant Disorder in the adolescents. The
internalizing/avoidant subtype was associated with Avoidant PD and Depression. The
adult emotionally dysregulated and adolescent impulsive dysregulated subtypes were
strongly associated with Borderline PD.

However, some results were different than expected. For example, the subtypes
were not differentiated based on Generalized Anxiety Disorder (GAD) in the adult or
adolescent sample. Interestingly, although not signiﬁcant, in the adolescent sample the
resilient subtype had the highest rates of GAD. It may be that, although resilient, these
high functioning adolescents are predisposed to higher levels of stress and anxiety, which
may in part be associated with the traumatic separation. Attachment theory suggests that
anxiety is a key force in maintaining contact and safety in the face of threats to security

(Bowlby, 1969). Resilient individuals with higher levels of anxiety may have attachment

70

systems that are overactivated due to a learned heightened sensitivity response. While in
some cases this anxiety may be associated with Axis I pathology, at other times it may be
an adaptive quality that once helped maintain contact in the face of an attachment
disruption.

In the adolescent sample, the subtypes were also not signiﬁcantly differentiated
by ADHD. This suggests that the impulsivity that is a feature of some of the personality
subtypes is unlikely to be attributable to an Axis I ADHD diagnosis but instead is a facet
of personality. Another explanation for ADHD not differentiating the subtypes may
include issues related to the diagnostic subtypes of the disorder, which include
Inattentive, Hyperactive, and Combined subtypes. Previous research on children with
different subtypes of ADHD suggests that aspects of child temperament and different
types of parenting styles interact, resulting in either ambivalent or avoidant attachment
(Finzi-Dottan, Manor, & Tyano, 2006). Research considering personality traits has found
that inattentive symptoms are associated primarily with low conscientiousness and that
the hyperactive-impulsive symptoms are associated with low agreeableness (N igg et al.,
2002; Parker, Majeski, & Collin, 2004). In a study of comorbid psychopathology, ADHD
was signiﬁcantly associated with both cluster B and cluster C DSM-IV PDs, without any
differentiation by ADHD subtype (Miller, Nigg, & Faraone, 2007). Therefore, the
previous research suggests that personality development in individuals with ADHD is
likely a complex pattern that relates to both temperament traits and parenting responses.
While personality traits may explain differences in subtypes, other studies of personality
pathology have not found differences between ADHD subtypes in relation to different

Axis II diagnoses. In the present study, ADHD does not signiﬁcantly differ across

71

personality subtypes, but did show small signiﬁcant associations with the adolescent
impulsive dysregulated and psychopathic subtypes (Table 16).

One other ﬁnding that was somewhat different than expected was with regard to
Paranoid PD. While the adult subtypes did differ signiﬁcantly on rates of this disorder, it
was notable that three of the subtypes had elevated rates of this PD (emotionally
dysregulated 50%, psychopathic 54%, and hostile/paranoid 55%). While previous
research has found that Paranoid PD and Antisocial PD are highly comorbid (Fonagy et
al., 1996), another possible explanation for the elevated rates of paranoid
symptomatology may be driven by the presence of traumatic separation. Future studies
should assess whether the experience of the separation results in the child forming a
belief that others will be inaccessible and unresponsive resulting in a schema that reﬂects
others’ untrustworthiness. Overall, the hostile/paranoid subtype is unlikely to be
differentiated from the other subtypes simply by the presence or absence of the DSM-IV
Paranoid PD diagnosis.

Personality Subtypes in Relation to Developmental History and Family History

Criterion Variables
After considering rates of Axis I and II psychopathology, additional criterion

variables related to adaptive functioning, developmental history, and family history were
used to provide further support for the subtypes identiﬁed in each sample. As expected,
the emotionally dysregulated subtypes and the psychopathic subtypes were characterized
by the lowest global adaptive functioning, suggesting that these subtypes were most
impaired. It was anticipated that these individuals would have the most difﬁculties in

terms of their relationships and functioning at work or school. Interestingly, the

72

internalizing/avoidant subtypes had the highest global adaptive frmctioning after the
resilient subtype, suggesting that this personality presentation interferes least with general
functioning. Therefore, personality constellations dominated by dysregulation and
deﬁcits in empathy are associated with the greatest general impairment.

In terms of number of conﬁdants, the resilient group, as expected, was
characterized by a greater number of close relationships than the other subtypes. Within
the adult sample, the hostile/paranoid subtype and psychopathic subtypes were most
impaired in this area. The hostile/paranoid individuals appear to be outcasts who likely
stay away from people, because of their suspicious, critical, and controlling styles. This
contrasts with those in the psychopathic subtype who likely have a lower number of
conﬁdants due to their tendency to manipulate and exploit others without regard for their
welfare. Interestingly, individuals in the psychopathic subtype appeared to seek out
others to use for their own purposes, while the hostile/paranoid subtype’s intense mistrust
leads them to isolate themselves. Common to both is the intense anger that pervades their
personalities. This corresponds to the theoretical work of Meyer and Pilkonis (2005) who
suggest that those with Antisocial personality utilize a “dismissing” attachment style in
which their sense of self as superior leads them to manipulate others, while those with
Paranoid personality pathology use a mixed ‘Tearful-dismissing” attachment style. For
these individuals this mixed-style results in a primarily negative self-view that is beneath
a facade of superiority and a general mistrust of others despite their desire for nurturance.

Within the adolescent sample, the psychopathic subtype also had fewer
conﬁdants; however, as expected, the lowest number of conﬁdants was associated with

the immature dysregulated group. The childishness and underdeveloped social skills

73

characteristic of the immature dysregulated group likely limits their capacity to form rich
conﬁding mutual relationships, regardless of whether they desire them. The deﬁcits in
reﬂective functioning (i.e., thinking about others’ mental states) within this subtype may
relate to the longitudinal research following Romanian adoptees, which has identiﬁed a
subgroup who have persistent underdeveloped abilities with both theory of mind and
perceptions of emotional expression in others, which results in poor peer relationships
(Rutter et al., 2007). More generally, attachment security in adolescents is correlated with
better peer relationships (Allen, Porter, McFarland, McElhaney, & Marsh, 2007;
Lieberman, Doyle, & Markiewicz, 1999). The number of conﬁdants within the
intemalizing/avoidant subtypes was higher than expected, which perhaps is attributable to
the lack of severity associated with the subtype. While socially avoidant and shy, these
adolescents still are able to relate with others to form some meaningful relationships.

Rates of criminality and early-onset delinquency followed the expected patterns.
Given the literature regarding the criminal activity of psychopaths, the high rates
associated with this subtype were not surprising. Similarly, the impulsive behaviors
associated with Borderline personality pathology suggest that these individuals would
also be more likely to engage in illicit activity (F onagy et al., 1997).

Histories of suicide attempts were most strongly associated with the adult
emotionally dysregulated and adolescent impulsive dysregulated subtypes. A number of
studies have previously documented the association between both suicide attempts and
parasuicidal behavior with aspects of affective dysregulation common to Borderline

personality pathology (Links et al., 2007; Yen et al., 2004).

74

Sexual abuse related most to the adult emotionally dysregulated and adolescent
impulsive dysregulated subtypes. These results are consistent with previous research
linking childhood sexual abuse to Borderline PD, which is characterized by dysregulated
affect (Ogata et al., 1990; Westen et al., 1990; Zanarini, 1997). This ﬁnding has
implications for understanding the ways in which multiple interpersonally traumatic
developmental antecedents are associated with affective dysregulation. In childhood,
these individuals faced multiple risk factors relating to being cared for and protected. In
fact, factors such as family stability mediate these effects (Bradley, Jenei et al., 2005),
and others have conceptualized childhood abuse as sometimes symptomatic of difﬁculties
within the attachment relationship (Alexander, 1992). This is consistent with a
mentalization perspective in which the absence of parental mirroring leads to affective
states that are undifferentiated, outside of awareness, and dysregulated (F onagy et al.,
2002). Overall, developmental history variables were associated with the subtypes in
ways that were consistent with previous theory and research.

In contrast to the developmental history variables, family history variables were
less successful in differentiating the subtypes, perhaps because of lack of reliability, or
simply because family history of a class of disorders is too blunt an instrument for
detecting gene-environment interactions (especially when the disorders themselves
include substantial psychosocial inﬂuences). A family history of an anxiety disorder did
not differentiate the subtypes in either sample. This unexpected result was consistent with
the earlier ﬁnding that GAD diagnosis did not signiﬁcantly differentiate the subtypes.

Subtypes were, however, distinguished in both samples by family history of

criminality, with the psychopathic subtypes showing the highest rates. This is consistent

75

with the literature identifying the heritability of both callous-unemotional traits and the
absence of empathy common to psychopathy (Blair et al., 2006; Wootton et al., 1997).
From a diathesis-stress perspective, it may be that individuals in this group who were
already vulnerable to developing this personality style were at increased risk following
the experience of traumatic separations and other correlated risk factors. In this case, a
genetic predisposition for psychopathy may account for the covariance between
temperament variables and variables affecting the family environment (e.g., parental
consistency, warmth, and empathic responses) (Shiner, 2006). Alternatively, parents who
pass on the genes that predispose their children to early-onset delinquency may be more
likely to abandon their children.

Overall, the criterion variables were able to provide some initial validity for the
distinct subtypes of individuals with traumatic separations. At times, the dimensional
analyses were able to reveal some interesting ﬁndings that were unapparent when using
an arbitrary cut-off to treat the subtypes categorically. For example, although the
categorical results did not support differences between groups on GAD or family history
of an anxiety disorder, in the adolescent sample the psychopathic personality dimension
showed a signiﬁcant negative correlation with both variables, which is consistent with
both theoretical and more recent empirical perspectives of psychopathy (F rick, Lilienfeld,
Ellis, Loney, & Silverthorn, 1999). While the contrast analyses allowed for the testing of
a priori hypotheses, a dimensional view of the personality Q factors provided a rich
perspective that incorporated all of the data.

In summary, using contrast analyses, Axis I and II psychopathology signiﬁcantly

differentiated the subtypes, with the exception of GAD and ADHD. The subtypes were

76

also well differentiated by both adaptive functioning and individual history variables. The
emotionally dysregulated and psychopathic subtypes were associated with the lowest
adaptive functioning and the greatest number of risk factors. The hostile/paranoid subtype
in adulthood was most differentiated by having a combination of low conﬁdants,
Paranoid PD, and less antisocial activity than those in the psychopathic group. The
resilient subtype was consistently associated with relatively low levels of
psychopathology and the fewest developmental risk factors. Least successful in
differentiating the subtypes were family history variables. This may suggest that for
patients who have experienced traumatic attachment disruptions, certain genetic
inﬂuences may be less useful in differentiating their overall personality proﬁles. The
exception to this was criminality, which did differentiate the subtypes and was consistent
with previous ﬁndings suggesting a strong heritable component to psychopathic
tendencies.
Incremental Validity

In the ﬁnal analyses, the incremental validity of the personality dimensions in
predicting adaptive functioning, while controlling for demographic variables and histories
of childhood trauma, was tested. Demographic variables, particularly socioeconomic
status, predicted a substantial portion of the variance in global adaptive functioning. This
suggests that for patients with separation histories, the correlates of having a low income
greatly affect their functioning in the domains of psychological health, work or school,
and relationships. It also indicates that factors related to socioeconomic status (e. g., the
availability of resources) should be considered when working with such patients in

clinical settings. However, even when controlling for these variables and childhood

77

trauma, the addition of the personality dimensions predicted a signiﬁcant and substantial
portion of incremental variance in adaptive functioning. These ﬁndings suggest that
personality is an important predictor of functioning and should be considered along with
developmental history variables and important demographic variables. The attention to
personality dimensions may help clinicians in formulating their conceptualization of the
presenting problem and plans for structuring treatment.

In the adolescent sample, impulsive dysregulated and psychopathic features were
signiﬁcant predictors of lower functioning, while the resilience dimension was a predictor
of higher functioning. Within the adult sample, only the resilient dimension was
predictive of higher global adaptive functioning. When considering the personality
dimensions independently, the results draw attention in both samples to the role of
resiliency in adaptive functioning. When controlling for demographic risk factors and
trauma, those with traumatic separations whose personalities were characterized as
articulate, likable, able to maintain caring relationships, energetic, driven, and responsible
were likely to be adapting well to their worlds. This is consistent with longitudinal
research ﬁ'om Hauser and Allen (2006) who studied the narratives of at-risk youth. They
identiﬁed agency, persistence, self-esteem, complexity of thought, and narrative
coherence as descriptive qualities of the adolescents who became higher functioning. The
adolescents described relationships with narratives rich in reﬂective functioning. By
knowing which qualities are not only characteristics of resilience but also predictive of
adaptive functioning, clinicians will be able to have goals that are more clearly tied to
empirical data, and better ways to assess therapeutic change.

Limitations

78

This research had several limitations. First, data in this study were cross-
sectional. Without longitudinal prospective data it is impossible to make causal
statements about the impact of the traumatic separation on personality development.
While one possibility is that an attachment disruption has a lasting impact on personality,
another possibility suggests that personality characteristics were already present prior to
the separation. Additionally, other factors that are correlated with the presence of
separations, rather than the separation itself, may have been more inﬂuential to the
formation of different personality constellations. While attempts were made to account
for some of these differences (e. g., controlling for socioeconomic status, education,
gender, and age) it was not possible to fully account for confounding variables. In
addition, it was notable that the personality dimensions did account for a signiﬁcant
amount of the variance in global adaptive functioning over and above childhood traumas
and socioeconomic status.

Second, within this study a single informant (i.e., the treating clinician) described
each patient. Future research should use multiple informants including the self-report of
the patient. This would be beneﬁcial both in terms of assessing personality, but also in
terms of gathering information regarding the separation and the other criterion variables.
Relatedly, this study had relatively little speciﬁc information regarding the nature of the
separation. While exploratory analyses revealed that subtypes did not differ based on age
0f separation or trauma severity associated with the separation, it is possible that other
factors related to the precise quality of the separation would have helped to further
differentiate the subtypes. For example, prolonged traumatic separations due to a parent’s

illness, being placed in foster care, having a parent in the military who is deployed in

79

combat, or having a parent incarcerated are likely quite different experiences. In addition,
this study suggested that certain aspects of the social environment were associated with
different subtypes. The precise nature of the contribution of environmental risk and
protective factors to personality development would be useﬁrl for understanding ways to
assist patients who have experienced attachment disruptions.

Finally, this study utilized data from a clinical sample and may not reﬂect the
more general population. While subjects were not initially recruited based on their
patients’ histories of separations, it is possible that psychopathology was overrepresented
in the sample. The presence of a resilient subtype provides support for the need to
consider aspects of personality strengths as part of personality assessment.

Directions for Future Research

As discussed in the limitations section, the results of this study should be
extended using prospective longitudinal studies that rely on multiple informants. There
are also some additional, broader domains that would beneﬁt from future inquiry.

First, theoretically, IWMs should mediate the development of personality
following traumatic separations. However, beyond looking at SWAP items that are
reﬂective of qualities speciﬁc to IWMs, this study did not directly assess attachment style
or IWMs. Future research should use a measure of attachment security to directly assess
IWMs in relation to personality for those with traumatic separations. It may be that the
individuals with more severe symptomatology and lower global adaptive functioning are
most likely to have insecure or even disorganized attachment. In contrast, it is expected
that the resilient subtypes would most likely display secure attachment strategies given

the higher global adaptive functioning and greater number of conﬁdants. It would be

80

useful to compare ﬁndings from the traditional measures of attachment to clinical rating
scales of attachment (both clinician and patient self report), as these would be more easily
utilized within clinical settings. Another issue to address is the speciﬁc relationship
between the subset of items within the SWAP that are descriptive of relational dynamics
and representations of self/other and scales from other measures assessing IWMs. This
would further clarify the relationship between the domains of personality and attachment.
In addition to assessing the IWM of the individual who faced the separation, it
would also be important to consider the role of IWM of the caregiver in relationship to
child personality development. A growing body of research suggests that parents’ own
representations of relationships may inﬂuence aspects of the child’s personality and
IWMs (Abrams, Riﬂdn, & Hesse, 2006; Crowell & Feldman, 1988; Main & Hesse, 1990;
Zeanah, Zeanah, & Stewart, 1990). For example, it would be interesting to see the ways
in which caregivers utilize their own representations of relationships to help the child
process and make meaning around the experience of the traumatic separation. Parents
with their own histories of unresolved loss and trauma, may be less able to be affectively
present and attentive to their children at such times, which may leave the child to utilize
self-soothing or inconsistent strategies for emotional regulation. Similarly, researchers
developing foster care interventions have emphasized the importance of caregivers
reﬂecting and resolving relational issues from their own childhood that may prevent them
from being fully emotionally available and attuned to their foster child, who very likely
has suffered a traumatic separations (Dozier & Bick, 2007; Dozier et al., 2005).
Therefore it may be that caregiver’s IWMs play an important role in the developmental

trajectories of personality following a traumatic separation.

81

Finally, the study of traumatic separations in relation to personality development
needs to further untangle the role of genes, environment, and gene-environment
interactions. One possible way to address these issues would be through the use of
behavior genetic research designs such as adoption studies or those including families
with half-siblings following a divorce. Interestingly, some of these research designs by
their nature include the presence of a potentially traumatic separation. The results of
previous behavior genetics studies suggest that when environment accounts for
differences in the traits and behavior, it is generally non-shared environment (Plomin &
Caspi, 1999; Scarr, 1996). However, more recently research has found substantial
portions of the variance in infant attachment classiﬁcations are attributable to shared
environment (Bokhorst et al., 2003). It would be interesting to assess the relationship
between attachment classiﬁcation and personality utilizing behavior genetics
methodology. An ideal study would simultaneously be able to gather more speciﬁc data
regarding the separation and the way the separation was experienced for the child.
Therefore, a behavior genetics research design may provide an opportunity to both assess
parent-child relationships, personality development, and the variance in personality
outcomes attributable genes and environment.

Clinical Implications
The presence of personality subtypes among individuals with histories of
traumatic separations has important clinical implications for both case formulation and
intervention. In terms of case formulation, it provides support for both being thoroughly
attentive to developmental history variables and also completing an assessment of

personality characteristics. Traumatic separations do not result in a single patient

82

prototype or pattern of symptomatology. This study identiﬁed subgroups of people who
differ in their developmental histories, relationships, global functioning, and co-occurring
psychopathology. Therefore, a careful assessment of personality from the onset of
treatment would likely assist clinicians formulate their understanding of the patient and
plan a treatment that will be most appropriate for those with a particular constellation of
personality characteristics. The data support the use of personality as an overarching
framework for organizing more general symptomatology.

The results of this study suggest that patients with histories of attachment
disruption will not be best served by treatments that try to address discrete Axis I disorder
(Westen & Bradley, 2005). Instead, working with these patients requires understanding
how personality informs their Axis I symptomatology. For example, in the adult sample,
high rates of substance use disorders are common to both the emotionally dysregulated
and psychopathic subtypes. It may be, however, that treating a substance disorder without
considering the way that personality shapes the prognosis and both motivation and
experience of the behavior ignores factors that will affect the treatment process.

Next, in working through and resolving issues related to the traumatic separation,
treating clinicians need to consider how personality may be affecting clinical
presentations. While attachment research has begun to inform adult psychotherapy
(Slade, 2008), this study suggests that this work should be expanded to further understand
the role of attachment disruptions in personality development. This would build upon the
work of mentalization therapies (Bateman & Fonagy, 2004) and research considering
therapeutic outcomes of those classiﬁed as Unresolved on the AAI.

Conclusion

83

In summary, this research identiﬁed personality subtypes within samples of adult
and adolescent patients with histories of traumatic separations. Consistent with Bowlby’s
expectations, attachment disruptions are associated with a range of personality proﬁles
that are likely related to genetic, environmental, and the gene-environment interactions.
Initial support for the validity of the subtypes was established through the expected
associated patterns of psychopathology and developmental history variables. Family
history variables were less successful at differentiating the subtypes, with the exception
of criminality, which was consistent with literature suggesting the heritability of
psychopathic personality. Future research should address limitations of this research by
using prospective longitudinal studies and data collected by multiple methods and ﬁ'om
multiple reporters. There is also a need to further deﬁne the role of IWMs in relation to
personality development. Finally, future studies assessing individuals with attachment
disruptions should utilize a range of personality assessment measures in order to explore
different representations of personality and personality pathology. Thus, the results of
this research emphasize the value of utilizing personality subtypes within case

formulation and treatment for individuals with histories of attachment disruptions.

84

APPENDIX A: TABLES

85

Table 1

Characteristics of Adolescent Patients with and without Childhood Traumatic
Separations from Attachment Figure *

 

Adolescents with Adolescents without t(dj) Sig.

 

Traumatic Traumatic
Separations Separations
(N = 236) (N=714I
Racea <. 01
Caucasian 66.0 82.9
Aﬁican American 13.6 5.9
Hispanic 12.8 5.3
Asian 3.0 2.5
Biracial or Other 4.7 3.4
SESa <. 01
Poor 17.5 2.1
Working class 32.9 14.7
Middle class 28.6 44.7
Upper middle class 15 32.4
Upper class 6 6
Agea .24
13 15.8 12.8
14 16.2 14.7
15 15.4 19.1
16 17.9 22.9
17 20.9 16.5
18 13.7 14.0
Settinga <.01
Private practice 49.6 77.0
Clinic/hospital 23 .9 1 6.3
outpatient
School 3 2.5

86

Table 1 (cont’d)

Inpatient/partial 3 .4 1 .7
program
Residential facility 12.8 1. 1
Forensic 5.1 1.1
Other 2.1 .3
Time in treatment 12.9 (10.8) 12.3 (9.9) -.20 .84
(months) Mean (SD) (934)
GAF - Mean (SD) 54.9 (9.9) 57.4 (9.7) 3.39 .001
(944)
IQ 106.6 (14.2) 112.0 (14.3) 5.04 .000
(935)
Comorbid Axis I Disorders
Major Depression 28 27 -. 14 .89
(947)
Dysthymia 40 41 .34 .73
(947)
Bipolar 8 7 -.32 .75
(947)
Generalized 8 16 3.8 .000
Anxiety Disorder (947)
PTSD 25 8 -5.77 .000
(947)
Social Phobia 5 9 2.25 .025
(947)
Sexual Disorder 6 2 -2.16 .03
(946)
Substance Use 25 15 -3.22 .001
Disorder (944)
ADHD 31 27 -1.16 .24
(947)
Conduct Disorder 22 12 -3.49 .001
(947)
Oppositional 40 32 -2.29 .02
Deﬁant Disorder (946)

 

. . a . . .
*Data are percentages unless otherwrse specrﬁed; Subscrrpt a denotes srgmﬁcance from

Chi-square test

87

Table 2

Composite S WAP-II-A Description of Adolescents with Traumatic Separations ﬁom
Attachment Figure (N = 236)

 

 

SWAP Items Mean
ranking
Tends to feel unhappy, depressed, or despondent. 3.86
Tends to feel misunderstood, mistreated, or victimized. 3.81
Tends to be impulsive. 3.69“

Emotions tend to spiral out of control, leading to extremes of anxiety, 3.69
sadness, rage, etc.

Is rebellious or deﬁant toward authority ﬁgures; tends to be 3.67*
oppositional, contrary, quick to disagree, etc.

Tends to be angry or hostile (whether consciously or unconsciously). 3.64"
Tends to blame own failures or shortcomings on other people or 3.60"‘
circumstances; attributes his/her difﬁculties to external factors rather

than accepting responsibility for own conduct or choices.

Tends to fear s/he will be rejected or abandoned. 3.39
When upset has trouble perceiving the same qualities in the same 3.33“
person at the same time (e.g., may see others in black or white terms,

shift suddenly from seeing someone as caring to seeing him/her as

malevolent and intentionally hurtful, etc.)

Tends to be manipulative. 3.28*
Attempts to avoid feeling helpless or depressed by becoming angry 328*
instead.

Lacks close friendships and relationships. 3.15“
Is prone to intense anger, out of proportion to the situation at hand. 3.15*

Tends to be unreliable and irresponsible (e.g., may fail to meet school 3.13

or work obligations).

Has little psychological insight into own motives, behavior, etc. 3.1 1
Tends to give up quickly when frustrated or challenged. 3.10
ls articulate; expresses self well in words. 3.00
Tends to feel like an outcast or outsider. 3.00

 

I"indicates that the SWAP item mean was significantly higher (p<.05) in the separation group than the non-
separation group

88

Table 3

Correlations among the 5 Adolescent Personality SubQ/pes

 

lntemalizing/ Impulsive Immature
Psychopathic Avoidant Dysregulated Resilient Dysregulated
Psychopathic
Internalizing/ -.O6
Avoidant
Impulsive .25 .Ol
Dysregulated
Resilient .05 .04 .05
Immature .21 .l 3 .19 .06
Dysregulated

 

89

Table 4

Personality Subtypes of A dolescents with Traumatic Separations from Attachment

 

 

Figures in Childhood

Q factor 1- Psychopathic Mean
Is rebellious or deﬁant toward authority ﬁgures; tends to be oppositional, 3.35
contrary, quick to disagree, etc.
Tends to blame own failures or shortcomings on other people or 2.60
circumstances; attributes his/her difﬁculties to external factors rather than
accepting responsibility for own conduct or choices.
Tends to be angry or hostile (whether consciously or unconsciously). 2.60
Tends to be critical of others. 2.33
Has little empathy; seems unable or unwilling to understand or respond to others’ 2.26
needs or feelings.
Tends to be manipulative. 2.17
Attempts to avoid feeling helpless or depressed by becoming angry instead. 2.14
Tends to feel misunderstood, mistreated, or victimized. 2.04
Appears impervious to consequences; seems unable or unwilling to modify 2.02
behavior in response to threats or negative consequences.
Is prone to intense anger, out of proportion to the situation at hand (e.g., has rage 2.02
episodes).
Tends to hold grudges; may dwell on insults or slights for long periods. 1.96
Lacks close ﬁiendships and relationships. 1.94
Tends to be unreliable and irresponsible (e. g., may fail to meet school or work 1.89

90

Table 4 (cont’d)

 

 

 

obligations).

Tends to act impulsively (e.g., acts without forethought or concern for 1.89

consequences).

Takes advantage of others; has little investment in moral values (e. g., puts own 1.89

needs ﬁrst, uses or exploits people with little regard for their feelings or welfare,

etc.).

Experiences little or no remorse for harm or injury caused to others. 1.87

Tends to be dismissive, haughty, or arrogant. 1.81

Tends to be deceitful; tends to lie or mislead. 1.68
Q factor 2- Internalizing/A voidant Mean
Tends to feel unhappy, depressed, or despondent. 3.51
Tends to feel s/he is inadequate, inferior, or a failure. 2.68
Tends to feel like an outcast or outsider. 2.44
Is prone to painful feelings of emptiness (e.g., may feel lost, bereft, abjectly alone 2.39
even in the presence of others, etc.).
Tends to feel guilty (e.g., may blame self or feel responsible for bad things that 2.28
happen).
Tends to be shy or self-conscious in social situations. 2.25
Tends to fear s/he will be rejected or abandoned. 2.23
Tends to feel listless, fatigued, or lacking in energy. 2.17
Appears to ﬁnd little or no pleasure, satisfaction, or enjoyment in life’s activities. 2.15

91

Table 4 (cont’d)

Tends to feel ashamed or embarrassed. 2.02
Tends to avoid, or try to avoid, social situations because of fear of embarrassment 1.78
or humiliation.

Tends to feel helpless, powerless, or at the mercy of forces outside his/her control 1.77
(beyond what is warranted by the situation).

Is self-critical; sets unrealistically high standards for self and is intolerant of own 1.76

human defects.
Tends to feel anxious. 1.73
Has trouble acknowledging or expressing anger toward others, and instead 1.71

becomes depressed, self-critical, self-punitive, etc. (i.e., turns anger against self).

Tends to rurninate; may dwell on problems, replay conversations in his/her mind, 1.69
become preoccupied with thoughts about what could have been, etc.

Tends to be inhibited or constricted; has difﬁculty allowing self to acknowledge 1.68

or express wishes and impulses.

 

 

 

Tends to feel life has no meaning. 1.64
Q factor 3- Impulsive dysregulated Mean
Tends to act impulsively (e.g., acts without forethought or concern for 3.13
consequences).

Tends to abuse alcohol or drugs (beyond what is normative given his/her 3.00
age, background, etc.).

Emotions tend to spiral out of control, leading to extremes of anxiety, 2.64

92

Table 4 (cont’d)

sadness, rage, etc.

Tends to become attached quickly or intensely; develops feelings,
expectations, etc. that are not warranted by the history or context of the
relationship.

Tends to surround him/herself with peers who are delinquent or deeply
alienated.

Tends to feel unhappy, depressed, or despondent.

Tends to seek thrills, novelty, excitement, etc.; appears to require a high
level of stimulation.

Lacks a stable sense of who s/he is (e.g., attitudes, values, goals, and
feelings about self seem unstable or ever-changing).

Is sexually promiscuous for a person of his/her age, background, etc.
Relationships tend to be unstable, chaotic, and rapidly changing.

Is unable to soothe or comfort him/herself without the help of another
person (i.e., has difﬁculty regulating own emotions).

Tends to be sexually seductive or provocative (e.g., may be inappropriately
ﬂirtatious, preoccupied with sexual conquest, prone to use his/her physical
attractiveness to an excessive degree to gain notice).

Emotions tend to change rapidly and unpredictably.

Tends to be unreliable and irresponsible (e.g., may fail to meet school or

work obligations).

93

2.44

2.35

2.31

2.17

2.14

2.12

2.12

1.98

1.85

1.84

1.81

Table 4 (cont’d)

 

 

 

Tends to engage in self-mutilating behavior (e.g., self-cutting, self- 1.79
burning, etc.).

Tends to run away from home. 1.65
Tends to choose sexual or romantic partners who seem inappropriate in 1.64
terms of age, status (e.g., social, economic, intellectual), etc.

Has trouble acknowledging or expressing anger toward others, and instead 1.63
becomes depressed, self-critical, self-punitive, etc. (i.e., turns anger against

self).

Q factor 4- Resilient Mean
Has a good sense of humor. 3.24
Tends to be liked by other people. 3.17
Is articulate; can express self well in words. 2.78
Tends to be energetic and outgoing. 2.69
Enjoys challenges; takes pleasure in accomplishing things. 2.68
Is capable of sustaining meaningful relationships characterized by genuine 2.64
intimacy and caring.

Is able to assert him/herself effectively and appropriately when necessary. 2.43
Is able to use his/her talents, abilities, and energy effectively and 2.22
productively.

Appears comfortable and at ease in social situations. 2.16

94

Table 4 (cont’d)

 

 

 

Has moral and ethical standards and strives to live up to them. 2.11
Is empathic; is sensitive and responsive to other peoples’ needs and 2.08
feelings.
Tends to be conscientious and responsible. 1.96
Has areas of accomplishment or achievement other than school (e.g., 1.93
sports, music, etc.) for which s/he gains considerable recognition.
Generally ﬁnds contentment and happiness in life’s activities. 1.82
Tends to feel anxious. 1.70
Has the capacity to recognize alternative viewpoints, even in matters that 1.65
stir up strong feelings.
Finds meaning and satisfaction in the pursuit of long-term goals and 1.63
ambitions.
Tends to express anger in passive and indirect ways (e.g., may make 1.60
mistakes, procrastinate, forget, become sulky, etc.).
Q factor 5- Immature Dysregulated Mean
Seems childish for his/her age (e. g., acts like a younger child or primarily
chooses younger peers). 2.87
Emotions tend to spiral out of control, leading to extremes of anxiety,
sadness, rage, etc. 2.84
When upset, has trouble perceiving both positive and negative qualities
in the same person at the same time (e.g., may see others in black or 2.64

95

Table 4 (cont’d)

white terms, shift suddenly from seeing someone as caring to seeing
him/her as malevolent and intentionally hurtful, etc.).

When distressed, tends to revert to earlier, less mature ways of coping
(e. g., clinging, whining, having tantrums).

Has little psychological insight into own motives, behavior, etc.
Tends to be needy or dependent.

Tends to think in concrete terms and interpret things in overly literal
ways; has limited ability to appreciate metaphor, analogy, or nuance.
Tends to have extreme reactions to perceived slights or criticism (e. g.,
may react with rage, humiliation, etc.).

Is unable to soothe or comfort him/herself without the help of another
person (i.e., has difficulty regulating own emotions).

Tends to become irrational when strong emotions are stirred up; may
show a signiﬁcant decline from customary level of functioning.

Lacks social skills; tends to be socially awkward or inappropriate.
Has difﬁculty making sense of other people’s behavior; tends to
misunderstand, misinterpret, or be confused by others’ actions and
reactions.

Emotions tend to change rapidly and unpredictably.

Is prone to intense anger, out of proportion to the situation at hand (e.g.,

has rage episodes).

96

2.49

2.40

2.38

2.16

2.14

2.07

2.03

1.97

1.94

1.93

1.90

Table 4 (cont’d)

Tends to blame own failures or shortcomings on other people or
circumstances; attributes his/her difﬁculties to external factors rather
than accepting responsibility for own conduct or choices.

Tends to feel misunderstood, mistreated, or victimized.

Tends to be ignored, neglected, or avoided by peers.

Tends to fear s/he will be rejected or abandoned.

1.86

1.70

1.58

1.55

 

97

Table 5

Characteristics of Adult Patients with and without Traumatic Childhood
Separations ﬁom Attachment F igures”

 

 

Adults with Adults t (dﬁ Sig.
Traumatic without
Separations Traumatic
(N=203) Separations
(N=988)
Race a <.01
Caucasian 76.2 83.9
African American 12.4 5.4
Hispanic 6.9 5.8
Asian 1.0 2.4
Biracial or Other 3.5 2.5
SES 3 <.01
Poor 13.8 4.2
Working class 26.6 27.4
Middle class 31.5 40.6
Upper middle class 22.2 24.4
Upper class 5.9 3.7
Age: Mean(SD) 41.40 42.48 (12.15) 1.13 (1183) .26
(13.10)
Education a ('01
Less than high school 11.8% 3.0%
High school 17.7% 18.4%
Some college 26.1% 24.4%
College 18.2% 25.3%
Graduate School 26.1% 28.8%

98

Table 5 (cont’d)

a
Setting

Private practice
Clinic/hospital
outpatient
School
Inpatient/partial
program
Residential facility
Forensic
Other
Time in treatment (months)
Mean (SD)
GAF - Mean (SD)
Comorbid Axis I Disorders
Major Depression
Dysthymia
Bipolar
Bipolar
II/Cyclothymia
Generalized
Anxiety Disorder
PTSD
Social Phobia
Substance Use
Disorder
ADI-ID

66.5 74.4
17.7 16.6

.5 .7

5.4 3.4

1.5 .8

6.9 2.0

1.5 2.0

18.0 (24.3) 17.2 (19.7)
56.8 (10.7) 58.2 (10.7)
38 36

49 46

5 7

12

16 19

20 15

6 9

25 18

8 6

-.47 (1176)
1.67 (1188)
.38 (1189)
-.94 (1189)
.88 (1189)
-2.18 (1189)
.76 (1189)
-1.65 (1189)
1.39 (1189)

-2.29 (1189)

-1.15(ll89)

<01

.64

.71
.35
.38
.03

.45

.08

.17

.02

.25

 

*Data are percentages unless otherwise speciﬁed.

a
Sabscript a denotes signiﬁcance from Chi-square test

99

Table 6

Composite S WAP-II Description of Adults with Lengthy Traumatic Caregiver

Separations (N = 203)

 

 

SWAP Items Mean
ranking
Tends to fear s/he will be rejected or abandoned. 4.04
Tends to feel unhappy, depressed, or despondent. 4.04
Is articulate; can express self well in words. 3.87
Tends to feel anxious. 3.84
Tends to feel misunderstood, mistreated, or victimized. 3.61
Tends to feel s/he is inadequate, inferior, or a failure. 3.49
Tends to be conscientious and responsible. 3.33
Tends to be angry or hostile (whether consciously or unconsciously). 3.32*
Tends to feel like an outcast or outsider. 3.27
Has moral and ethical standards and strives to live up to them. 3.24
Tends to be needy or dependent. 3.22
Tends to feel guilty (e.g. may blame self or feel responsible for bad
things that happen). 3.2
Tends to feel helpless, powerless, or at the mercy of forces outside
his/her control. 3.12
Tends to react to perceived slights or criticism with rage and
humiliation. 3.1 1 *
Is prone to painful feelings of emptiness (e.g., may feel lost, bereft,
abjectly alone even in the presence of others, etc.). 3.1
Tends to ruminate; may dwell on problems, replay conversations in
his/her mind, become preoccupied with thoughts about what could have
been, etc. 3.06
Tends to be critical of others. 304*
Emotions tend to spiral out of control, leading to extremes of anxiety,
sadness, rage, etc. 3.03

 

I"indicates that the SWAP item mean was signiﬁcantly higher (p<.05) in the separation group than

the non-separation group

100

Table 7

Correlations among the Adult Personality Subtypes

 

Internalizing/ Emotionally Resilient Hostile/ Psychopathic

 

Avoidant DysreMed Paranoid
Intemalizing/
Avoidant
Emotionally .09
dysregulated
Resilient .19 -.04
Hostile/ .01 . 1 5 .02
Paranoid

Psychopathic -.25 .1 1 -.05 .15

 

101

Table 8

Personality Subtypes in Adults with Traumatic Separations ﬁ'om Attachment

 

 

Figures in Childhood

Q factor I- Internalizing/A voidant Mean
Tends to feel s/he is inadequate, inferior, or a failure. 2.92
Tends to feel guilty (e. g., may blame self or feel responsible for bad 2.83
things that happen).

Tends to feel anxious. 2.74
Tends to feel unhappy, depressed, or despondent. 2.72
Tends to feel ashamed or embarrassed. 2.72
Tends to be passive and unassertive. 2.39
Tends to be shy or self-conscious in social situations. 2.37
Has trouble acknowledging or expressing anger toward others, and 2.33
instead becomes depressed, self-critical, self-punitive, etc. (i.e., turns

anger against self).

Tends to fear s/he will be rejected or abandoned. 2.20
Has difﬁculty acknowledging or expressing anger. 2.14
Tends to feel helpless, powerless, or at the mercy of forces outside 2.05
his/her control.

Has moral and ethical standards and strives to live up to them. 1.96
Tends to be inhibited or constricted; has difficulty allowing self to 1.95
acknowledge or express wishes and impulses.

Is self-critical; sets unrealistically high standards for self and is intolerant 1.93

of own human defects.

102

Table 8 (cont’d)

Tends to avoid social situations because of fear of embarrassment or

1.91

 

 

 

humiliation.
Tends to feel like an outcast or outsider. 1.75
Tends to rurninate; may dwell on problems, replay conversations in 1.73
his/her mind, become preoccupied with thoughts about what could have
been, etc.
Tends to be conscientious and responsible. 1.7 0
Q factor 2- Emotionally Dysregulated Mean
Emotions tend to spiral out of control, leading to extremes of anxiety, 3.72
sadness, rage, etc.
Tends to become irrational when strong emotions are stirred up; may show 3.40
a signiﬁcant decline from customary level of functioning.
Tends to have extreme reactions to perceived slights or criticism (e. g., may 2.65
react with rage, humiliation, etc.).
Emotions tend to change rapidly and unpredictably. 2.63
Is prone to intense anger, out of proportion to the situation at hand (e. g., 2.53
has rage episodes).
ls prone to painful feelings of emptiness (e.g., may feel lost, bereft, 2.32
abjectly alone even in the presence of others, etc.).
Tends to fear s/he will be rejected or abandoned. 2.32
When upset, has trouble perceiving both positive and negative qualities in 2.28

103

Table 8 (cont’d)
the same person at the same time (e. g., may see others in black or white
terms, shift suddenly from seeing someone as caring to seeing him/her as

malevolent and intentionally hurtful, etc.).

 

 

 

Is unable to soothe or comfort him/herself without the help of another 2.14
person (i.e., has difﬁculty regulating own emotions).

Lacks a stable sense of who s/he is (e.g., attitudes, values, goals, and 2.14
feelings about self seem unstable or ever-changing).

Tends to act impulsively (e. g., acts without forethought or concern for 2.02
consequences).

Tends to be angry or hostile (whether consciously or unconsciously). 1.95
Tends to feel misunderstood, mistreated, or victimized. 1.90
Tends to feel unhappy, depressed, or despondent. 1.86
When distressed, perception of reality can become grossly impaired (e.g., 1.85
thinking may seem delusional).

Tends to become attached quickly or intensely; develops feelings, 1.73
expectations, etc. that are not warranted by the history or context of the

relationship.

Relationships tend to be unstable, chaotic, and rapidly changing. 1.71
Tends to be needy or dependent. 1.67
Q factor 3- Resilient Mean
Is articulate; can express self well in words. 3.68

104

Table 8 (cont’d)

Tends to be conscientious and responsible.

Enjoys challenges; takes pleasure in accomplishing things.

Is able to use his/her talents, abilities, and energy effectively and
productively.

Tends to be energetic and outgoing.

Finds meaning and satisfaction in the pursuit of long-term goals and
ambitions.

Is able to assert him/herself effectively and appropriately when
necessary.

Has moral and ethical standards and strives to live up to them.

Has a good sense of humor.

Tends to be liked by other people.

Is capable of sustaining meaningful relationships characterized by
genuine intimacy and caring.

Is creative; is able to see things or approach problems in novel ways.
Is psychologically insightful; is able to understand self and others in
subtle and sophisticated ways.

Appears comfortable and at ease in social situations.

Tends to be competitive with others (whether consciously or
unconsciously).

Finds meaning and fulﬁllment in guiding, mentoring, or nurturing others.

Finds meaning in belonging and contributing to a larger community (e.g.,

105

3.13

3.02

2.72

2.50

2.46

2.45

2.43

2.35

2.28

2.10

2.09

2.04

1.91

1.89

1.84

1.80

Table 8 (cont’d)

organization, neighborhood, church).

 

 

 

Tends to be controlling. 1.63
Q factor 4- Hostile/Paranoid Mean
Tends to be critical of others. 3.43
Tends to hold grudges; may dwell on insults or slights for long periods. 2.94
Tends to be self-righteous or moralistic. 2.56
Tends to be angry or hostile (whether consciously or unconsciously). 2.54
Tends to be controlling. 2.48
Tends to feel misunderstood, mistreated, or victimized. 2.45
Tends to get into power struggles. 2.37
Lacks close friendships and relationships. 2.32
Is suspicious; tends to assume others will harm, deceive, conspire 2.21
against, or betray him/her.

Tends to feel unhappy, depressed, or despondent. 2.02
Tends to be dismissive, haughty, or arrogant. 1.85
Tends to ruminate; may dwell on problems, replay conversations in 1.84

his/her mind, become preoccupied with thoughts about what could have

been, etc.

Tends to blame own failures or shortcomings on other people or 1.82
circumstances; attributes his/her difﬁculties to external factors rather

than accepting responsibility for own conduct or choices.

106

Table 8 (cont’d)

Tends to be oppositional, contrary, or quick to disagree. 1.81
Tends to have extreme reactions to perceived slights or criticism (e.g., 1.76
may react with rage, humiliation, etc.).

Tends to be overly concerned with rules, procedures, order, organization, 1.63
schedules, etc.

Has an exaggerated sense of self-importance (e. g., feels special, superior, 1.58

grand, or envied).

 

 

 

Tends to feel like an outcast or outsider. 1.49
Q factor 5- Psychopathic Mean
Has little empathy; seems unable or unwilling to understand or respond to 2.91

others’ needs or feelings.

Tends to be deceitful; tends to lie or mislead. 2.79
Tends to act impulsively (e. g., acts without forethought or concern for 2.72
consequences).

Has little psychological insight into own motives, behavior, etc. 2.62
Tends to abuse drugs or alcohol. 2.51
Tends to be manipulative. 2.50
Tends to be unreliable and irresponsible (e.g., may fail to meet work 2.50

obligations or honor ﬁnancial commitments).
Takes advantage of others; has little investment in moral values (e.g., puts 2.50

own needs ﬁrst, uses or exploits people with little regard for their feelings

107

Table 8 (cont’d)

or welfare, etc.).

Experiences little or no remorse for harm or injury caused to others.
Tends to engage in unlawful or criminal behavior.

Tends to show reckless disregard for the rights, property, or safety of
others.

Appears impervious to consequences; seems unable or unwilling to modify
behavior in response to threats or negative consequences.

Tends to be angry or hostile (whether consciously or unconsciously).
Tends to blame own failures or shortcomings on other people or
circumstances; attributes his/her difﬁculties to external factors rather than
accepting responsibility for own conduct or choices.

Tends to be conﬂicted about authority (e. g., may feel s/he must submit,
rebel against, win over, defeat, etc.).

Work-life and/or living arrangements tend to be chaotic or unstable (e.g.,
job or housing situation seems always temporary, transitional, or ill-
deﬁned).

Seems unable to settle into, or sustain commitment to, identity-deﬁning
life roles (e. g., career, occupation, lifestyle, etc.).

Repeatedly convinces others of his/her commitment to change but then
reverts to previous maladaptive behavior; tends to convince others that

“this time is really different.”

2.43

2.30

2.06

2.03

1.93

1.93

1.84

1.81

1.77

1.72

 

108

Table 9

Percent of Sample Meeting Criteria for Subtypes as a Function of Presence or
Absence of Traumatic Separation

 

 

Separation No Separation
N (percent of Total) N (percent of Total)
Adolescents
Psychopathic“ 58 (24.6) 134 (18.8)
Intemalizing/Avoidant“ 33 (14.0) 141 (19.8)
Impulsive Dysregulated* 24 (10.2) 42 (5.9)
Resilient* 27 (11.4) 101 (14.2)
Immature Dysregulated 17 (7.2) 37 (5.2)
Not Classiﬁed 77 (32.6) 258 (36.2)
Total 236 (100) 713 (100)
Adults
Intemalizing/Avoidant* 60 (29.6) 337 (34.1)
Emotionally 28 (13.8) 104 (10.5)
Dysregulated“
Resilient 24 (11.8) 129 (13.1)
Hostile/Paranoid 20 (9.9) 60 (6.1)
Psychopathic" 22 (10.8) 39 (3.9)
Not Classiﬁed 49 (24.1) 319 (32.3)
Total 203 (100) 988 (100)

 

*indicates that when treated dimensionally the differences between those with and
without separations was signiﬁcant

109

Table 10

Demographic Variables by Adolescent Personality Subtype (in percentages unless

otherwise noted)

 

 

Psychopathic Internalizing/ Impulsive Immature
. Resilient
(N = 58) Avoidant Dysregulated Dysregulated
(N = 2 7)
(N=33) (N=24) (N=17)
Age: Mean(SD) 15.59
15.12 (1.56) 16.25 (1.22) 16.04 (1.57) 15.88 (1.93)
(1.80)
Sex
Female 27.6 57.6 79.2 40.7 41.2
Male 72.4 42.4 20.8 59.3 58.8
Race
Caucasian 60.3 63.6 66.7 70.4 88.2
African
24.1 15.2 0 14.8 0
American
Hispanic 13.8 6.1 25.0 11 1 11.8
Asian 1.7 3.0 4.2 0 0
Biracial or
0 12.1 4.2 3.7 0
Other
SES
Poor 22.4 6.1 17.4 7.4 23.5
Working
37.9 36.4 . 30.4 29.6 35.3
class
Middle class 25.9 30.3 17.4 33.3 29.4
U r middle
ppe 10.3 15.2 26.1 25.9 11.8
class
Upper class 3.4 12.1 8.7 3.7 0
Separation
Early (age 1-6) 29.3 42.4 25.0 33.3 41.1
Traumatic
Impact: 3.48 (1.23) 3.70 (.95) 4.00 (1.1) 3.56(l.05) 3.75 (.78)
Mean (SD)

 

110

Table 11

Demographic Variablesgby Adult Personalgy Subtype (in percentages)

 

 

Internalizing/ Emotionally Hostile/
Resilient Psychopathic
Avoidant Dysregulated Paranoid
(N = 24) (N = 22)
(N = 60) (N = 28) 0V = 20)
Age: Mean(SD) 38.57 40.00 51.84 35.45
42.95 (10.91)
(10.81) (14.19) (13.64) (13.04)
Sex
Female 53.3 85.7 58.3 35.0 13.6
Male 46.7 14.3 41.7 65.0 86.4
Race
Caucasian 69.5 82.1 87.5 95 45.5
African
11.9 10.7 0 5 40.9
American
Hispanic 13.6 3.6 8.3 0 9.1
Asian 1.7 0 0 0 O
Biracial or
3.4 3.6 4.2 0 4.5
Other
SES
Poor 6.7 28.6 4.2 0 36.4
Working class 28.3 21.4 25.0 20 31.8
Middle class 38.3 25.0 25.0 45 22.7
Upper middle
21.7 14.3 45.8 30 4.5
class
Upper class 5.0 10.7 0 5 4.5
Separation
Early (age 1-6) 23.3 28.6 33.3 35.0 40.9
Traumatic Impact: 3.60
3.63 (1.10) 3.64 (1.31) 3.92 (.93) 3.24(1.00)
Mean (SD) (123)

 

111

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117

Table 16

Correlations of Adolescent Subtypes with Criterion Variables N =236

 

 

Internalizing/ Impulsive Immature
Psychopathic Resilient
Avoidant Dysregulated Dysregulated
Axis 1
Major Depressive -.23“'" 27*" .01 -.16* -.04
Disorder
Generalized -.26*** .13“ -.22** .16“ -.08
Anxiety Disorder
Substance use .06 -.O8 37*" -.26*"'* -.13*
disorder
Conduct Disorder 32*“ -.39*" .20" -.15"' -.09
Oppositional .49*"”" -.27*** 28*" -.15"' 23*"
Deﬁant Disorder
Attention Deﬁcit .15“ -.20"‘* .1 1 .07 .16*
Hyperactive
Disorder
Axis II
Antisocial .47 *** -.52*" .46*** -.30"* .02
Borderline .10 -.16* 37*" -.37**"‘ .15*
Avoidant -.17** 35*" -.13* -.21"”" .09
Individual History
Variables
Global Adaptive -.46*** .18" -.42"”'”" 59*" -.42"”""'
Functioning Scale
Physical Abuse -.02 -.05 .1 1 -.24*** .04
Sexual Abuse -.09 -.03 .18” -.26" * .08
Number of -.22*"' -.10 -.01 32*" -.19"
Conﬁdantes
Early-onset 50*" -.47*** .47*** -.35"“"* .01
Delinquency
Suicidality -.05 .00 26*" -.34"”'”" .1 1
Family History
Variables
Anxiety Disorder -.13* .06 -.11 .16" -.05

118

Table 16 (cont’d)

Illicit Substance .13 -.06 .17*
Abuse
Criminality (1’t .22“ -.25*"'* .11
degree rel)
Suicidality -.10 .07 .01

-.01

-.15"'

_.21*#*

-.01

.03

.10

 

*p<.05, **p<.01, ***p<.001

119

Table 17

Correlations of Adult Subtypes with Criterion Variables N =203

 

 

Internalizing/ Emotionally Hostile/
Resilient Psychopathic
Avoidant Dysregulated Paranoid
Axis 1
Major Depressive .21" .1 1 -.05 .02 -.20"‘*
Disorder
Generalized .18" -.03 .1 l -.07 -.14
Anxiety Disorder
Substance use -.23** .27*** -.28*** -.08 36*"
disorder
Axis II
Antisocial -.53*** 35*" —.50*” .10 67*"
Borderline -.17* 54*" -.25"‘** -.01 .14“
Paranoid -.45**"' .41 "* -.39*" .40*** .41‘"
Avoidant .46" * * -.06 -. 12 -.07 -.35 * * "
Individual History
Variables
Global Adaptive 28*“ -.46*** 68*" -.27*** -.38***
Functioning Scale
Physical Abuse -.10 .45*** -.32*** -.08 .11
Sexual Abuse -.l9"* .19“ -.15* -.01 .18"‘
Number of .09 -.05 34*" -.28**"' -.18"‘
Conﬁdants
Criminality -.46*** .23" -.39*** .22" 52*"
Suicidality -.10 .45*** -.32*** -.08 .11
Family History
Variables
Anxiety Disorder -.05 .01 .02 -.03 .00
Illicit Substance -.13 27*" -.25*** -.01 .18"
Abuse
Criminality (1" -.20** .18“ -.13 .05 .16"
degree rel)
Suicidality -.14* .18" —.O9 .10 .03

 

*p<.05, **p<.01, ***p<.001

120

Table 18

Hierarchical Linear Regression Predicting Adolescent Global Adaptive
Functioning from Demographic Variables (Step 1), Childhood Trauma (Step 2),

and Personality Subtypes (Step 3)

 

 

M E E
Predictor b t E R R_2 Mae chime
M .39 .16 10.46 .001
Age .06 .94 .35
Sex -.02 -.37 .71
Race/Ethnicity .09 1 .50 .14
Socioeconomic Status .38 6.23 .001
m .43 .18 .03 .005
Age .04 .80 .43
Sex -.08 -1.49 .14
Race/Ethnicity .06 1 .34 .18
Socioeconomic Status .30 4.43 .001
Childhood Trauma -.19 -2.81 .005
M .74 .54 34.96 .001
Age .04 .80 .43
Sex -.08 -l .49 .14
Race/Ethnicity .06 1.34 .18
Socioeconomic Status .21 4.13 .001
Childhood Trauma -.08 -1.49 .14
Psychopathic Subtype -.20 -2.83 .005
Intemalizing/Avoidant
Subtype -.10 -1.55 .12
Impulsive Dysregulated
Subtype -.23 -3.99 .001
Resilient Subtype .36 6.60 .001
Immature Dysregulated
Subtype -.10 -1.85 .07

 

Note: Global Adaptive Functioning Composite variable = sum of standardized
ratings of GAF, personality functioning, quality of peer relationships, school

functioning, and social support (# of conﬁdants)

121

Table 19

Hierarchical Linear Regression Predicting Adult Global Adaptive Functioning

ﬁom Demographic Variables (Step 1), Childhood Trauma (Step 2), and
Personality Subtypes(Step 3)

 

 

M E E
Predictor r t 2 R Q wage Lhasa;
M .34 .12 6.53 .001
Age -.01 -.20 .84
Sex .10 1.54 .13
Race/Ethnicity .02 .29 .77
Socioeconomic Status .33 4.79 .001
§t_ep_2 .37 .13 3.6 .060
Age -.01 -.20 .84
Sex .08 1.21 .23
Race/Ethnicity .03 .42 .67
Socioeconomic Status .27 3.47 .001
Childhood Trauma -.14 -1.89 .06
S_tep_; .73 .53 31.97 .001
Age -.05 -.90 .37
Sex .15 2.55 .01
Race/Ethnicity - .00 .04 .97
Socioeconomic Status .17 2.95 .004
Childhood Trauma .05 .74 .46
Intemalizing/Avoidant
Subtype -.03 -.36 .80
Emotionally Dysregulated
Subtype -. 12 -1.93 .06
Resilient Subtype .53 8.23 .001
Hostile/Paranoid Subtype -.07 -1.10 .27
Psychopathic Subtype -.11 -1.12 .26

 

Note: Global Adaptive Functioning Composite variable = sum of standardized
ratings of GAF, personality functioning, quality of peer relationships, school
functioning, and social support (# of conﬁdants)

122

APPENDIX B: MEASURES

123

CLINICAL DATA FORM — ADOLESCENT

ABOUT YOU (THE CLINICIAN)

 

1. Discipline: Psychiatry Psychology Social Work Nursing
Other
2. Sex: Female Male
3. How would you describe your main theoretical orientation? (check one)
Biological Eclectic (If eclectic, please indicate approach that most informs
your work:)
Cognitive-Behavioral Biological Psychodynamic
Family Systems Cognitive-Behavioral Humanistic/experiential
Psychodynamic Family Systems Other eclectic
Humanistic/experiential Other
4. In what settings do you work? (check all that apply) Private practice
Clinic/hospital outpatient School Hospital inpatient/partial program
Residential facility Forensic Other

5. How many years of experience do you have post-training (i.e., post residency or licensure)? _

ABOUT THE PATIENT

DEMOGRAPHIC AND DIAGNOSTIC INFORMATION:
1. Age:
2. Sex: Female Male

3. Length of time in treatment with you (in months)

4. In what setting have you seen this patient? (check primary setting)

 

Private practice Outpatient Clinic School Hospital inpatient/partial program
Residential facility Forensic Other
Race/Ethnicity: Caucasian African-American Hispanic Asian Other

.°":"

Global Assessment of Functioning (GAF) (referring to the 0-100 scale below, write a number
between 0 and 100 here, being as speciﬁc as you can):

0 10 30 50 70 90 100
gross serious serious mild minimal
impairment/ impairment/ symptoms symptoms/ symptoms
psychotic psychotic recurrent problems
7. Family socioeconomic status (circle number): 1 2 3 4 5
poor working middle upper upper
class class middle class class
8. Current residence: Living with both parents Living with one parent (with or without
another adult in the home) Joint custody Foster home Residential facility

Living with other family members Other

9. Approximate IQ:

10. Does the patient have a learning disability? No Unsure Yes

124

1 1. Axis I diagnosis: Please read through the list below, and indicate whether the patient meets
DSM-I V criteria for each disorder. If you are unsure, check “No. ”

 

No Yes Major depressive disorder No Yes Sexual disorder

No Yes Dysthymic disorder No Yes Adjustment disorder

No Yes Bipolar disorder No Yes Anorexia, restricting type

No Yes Cyclothymia or bipolar II No Yes Anorexia, binge-purging type

No Yes Other mood disorder (e.g., NOS) No Yes Bulimia

No Yes Generalized anxiety disorder No Yes Other eating disorder (e.g.,
NOS)

No Yes Post-traumatic stress disorder No Yes Psychotic disorder

No Yes Social phobia No Yes Attention-deﬁcit
hyperactivity disorder

No Yes Panic disorder No Yes Psychiatric disorder due to

No Yes Obsessive-compulsive disorder general medical condition

No Yes Other anxiety disorder (e.g., NOS) No Yes Conduct disorder

No Yes Substance use disorder No Yes Oppositional deﬁant disorder

No Yes Dissociative disorder No Yes Separation anxiety disorder

No Yes Somatoform disorder (e.g., No Yes Other

hypochondriasis)

 

12. Axis II diagnosis: Please read through the list below, and indicate whether the patient meets
adult DSM-I V criteria for each disorder. If you are unsure, check “No. ”

No Yes Paranoid No Yes Narcissistic

No Yes Schizoid No Yes Avoidant

No Yes Schizotypal No Yes Dependent

No Yes Antisocial No Yes Obsessive-compulsive
No Yes Borderline No Yes Personality disorder NOS

No Yes Histrionic

13. Chronic level of personality functioning (circle number):

1 2 3 4 5
severe substantial high-
personality disorder problems in living functioning
14. Quality of peer relationships (circle number): 1 2 3 4 5
very poor or absent very good
15. School functioning (circle number): 1 2 3 4 5
severe conduct working
problems/suspensions to full potential
16. Has the patient ever attempted suicide? No Yes
If “yes”: Rate the most severe suicide attempt (circle number):
1 2 3 4 5
mild (primarily moderate (required serious
symbolic gesture) medical attention) (life-threatening)

17. Has the patient had psychiatric hospitalizations? No Yes
18. Approximately how many close current relationships has the patient described to you—people in

whom s/he feels comfortable conﬁding? None Very Few Some Many
19. Physical health (circle number): 1 2 3 4 5
serious or chronic or frequent few or occasional
degenerative illness illness that aﬂects health concerns
adaptive functioning

125

20. Approximately how often does the patient get minor illnesses such as the ﬂu, sore throats,
headaches, etc., that lead to missed appointments, days off school or work, visits to the doctor, or
subjective distress?

1 2 3 4 5
rarely occasionally very frequently
(1 or 2 times a year) (a few times a year) (many times per year)

DEVELOPMENTAL AND FAMILY HISTORY:

Note: For Developmental and Family History items below, please check "no" if you are unsure,
unless given the response option "unsure" or "unclear."
FAMILY ENVIRONMENT

 

 

For the items that follow, if the patient has had more than one mother- or father-ﬁgure,
choose the person most involved in rearing the patient (who will usually be the person the
patient considers his/her mother or father). If the patient had no enduring relationship with a
mother- or fath er-ﬂgure (e.g., if parents divorced early, father disappeared, and the moth er
never remarried), circle N/A (not applicable).

Unless otherwise specified, describe the patient ’3 childhood experience through age 16. In
cases in which the family environment changed dramatically at some point and remained
that way for several years, rate what you consider the most psychologically significant
period.

21. Patient has been reared primarily by: both biological parents biological mother (with or
without step-father) biological father (with or without step-mother) adoptive parents
foster parents other

22. Relationship with mother (circle number or N/A):

N/A 1 2 3 4 5
poor/ positive/
conﬂictual loving
23. Relationship with father (circle number or N/A):
N/A 1 2 3 4 5
poor/ positive/
conflictual loving
24. Mother’s psychological functioning (circle number or N/A):
N/A 1 2 3 4 5
psychotic personality disorder/ hi-functioning

severe recurrent Axis I
25. Father’s psychological functioning (circle number or N/A):
N/A 1 2 3 4 5
psychotic personality disorder/ hi-functioning
severe recurrent Axis I
26. Lengthy traumatic separations from primary caregiver for more than 6 weeks:

No Yes age 1-6 Yes, age 7-12 Yes, age 13-16
If. (yes 9".
To what extent did the patient experience the separation(s) as traumatic (circle number):
1 2 3 4 5
not at all moderately very
Frequency of separations (circle number):
1 2 3 4 5

once infrequently periodically ﬁequently permanently

126

27. Parental divorce/permanent separation:
No Yes, age 1-6 Yes, age 7-12 Yes, age 13-16 N/A (e.g., never lived
with both parents)
28. Mother died during patient’s childhood: No Yes age 1-6 Yes, age 7-12 Yes, age 13-16
29. Father died during patient’s childhood: No Yes age 1-6 Yes, age 7-12 Yes, age 13-16
30. Describe the stability of the primary caregiver’s sexual/romantic relationships (circle number or

N/A):
N/A 1 2 3 4 5
monogamous/ somewhat unstable/ multiple/
stable changing indiscriminate partners
31. Has the patient ever been in foster care? No Yes

If “yes”: Approximately how many placements has the patient been in?
32. Has the patient ever been sent to live with other family members or friends because of parental
difﬁculties providing a stable home life? No Yes
33. Have the parents or family ever been investigated for child mistreatment or neglect?
No Yes
34. Has the patient had an alcoholic parent or stepparent living in the home for a substantial period
of time? No Yes
35. Was the patient’s mother sexually abused as a child? No Unsure Yes
36. Approximate number of residence changes (family moves) during patient’s childhood, other
than those due to parental job transfers: 0-1 2-3 4-6 >6
37. Rate the extent to which the family environment has been predictable, stable, and consistent
(circle number):

1 2 3 4 5
chaotic predictable/consistent

38. Rate the extent to which the family environment has been warm and nurturing (circle number):
1 2 3 4 5
cold/hostile warm/nurturing

39. Has the patient had someone (other than a parent) s/he could consistently turn to for emotional
support during difﬁcult times in childhood (e.g., grandparent, family friend, teacher)?

 

 

 

No Yes
PHYSICAL & SEXUAL ABUSE
40. Has the patient been physically abused? No Unclear Yes (approximate age at ﬁrst
abuse: )
If “yes, ” (circle numbers):
Severity of physical abuse: 1 2 3 4 5
no physical injury bruises, welts broken
bones, burns, etc.
Frequency of physical abuse: 1 2 3 4 5
once periodic weekly
or more
41. Has the patient witnessed domestic violence? No Unclear Yes
42. Has the patient been sexually abused? No Unclear Yes (approximate age at ﬁrst
abuse: )

127

U “y“ ,9:

Severity of sexual abuse: (circle number): 1 2 3 4 5
non-contact oral sex penetration
exposure, kissing

Degree of force used (circle number): 1 2 3 4 5
minimal verbal coercion physical
violence/coercion
Frequency of sexual abuse (circle number): 1 2 3 4 5
once periodic weekly

Main perpetrator of sexual abuse (choose one): father step-father/mother’s lover
mother brother other relative non-relative

Approximate total number of perpetrators:
Did the patient disclose the sexual abuse to a parent (other than the abuser)? No Yes

If “yes”: How did parent(s) respond to the disclosure? (circle number):

1 2 3 4 5
denied abuse/ supportive,
blamed child accepting, help-seeking

CHILD/ADOLESCEN T BEHAVIOR

 

 

43.
44.
45.

Has the patient had enuresis (bed-wetting)? No Yes
Has the patient ever set ﬁres? No Yes
Has the patient tortured animals? No Yes

46. Has the patient run away from home? (circle number):
1 2 3 4 5
no a few times frequently
47. Has the patient abused alcohol or other illegal substances? No Yes (age began: _)
48. Has the patient initiated physical ﬁghts with peers? (circle number):
1 2 3 4 5
no a few times ﬁequently
49. Has the patient had problems at school with discipline, truancy, suspensions, etc.
No Yes (age began: _ )
50. General performance in school (circle number): 1 2 3 4 5
failing/ passing high

dropped out grades achievement

51. Has the patient gotten in trouble for chronic lying? No Yes (age began: _)

52. Has the patient had a problem with stealing? 1 2 3 4 5
no a few times frequently

53. Has the patient engaged in frequent or serious vandalism? No Yes

54. Has the patient committed violent crimes? (circle number):

1 2 3 4 5
no unarmed violence armed violence

(e. g., guns, knives, etc.)

55. Has the patient been involved in gang activity? No Yes

56. Has the patient committed crimes alone (without the involvement of others)? No Yes

128

57. Has the patient ever been arrested? (circle number): 1 2 3 4 5
no a few times frequently

58. Has the patient had sexual intercourse (excluding any sexual abuse)? No Unsure Yes

If “yes”: At what age did s/he ﬁrst have sexual intercourse (excluding any sexual abuse)?

59. Has the patient engaged in promiscuous sex? No Yes (age began: )

60. At what age was the patient’s ﬁrst contact with a mental health professional?

 

-—- PARENTAL PSYCHOPATHOLOGY AND FAMILY PSYCHIATRIC HISTORY-

Please do not leave any of the following questions blank. If you do not know, or if the data are
unclear, please mark “Unsure. ”

61. Please indicate any history of psychiatric disorders in the patient’s mother or father (or mother-
or father-ﬁgure, in cases in which the primary parental ﬁgures were not the biological parents).

Mother Father
No Unsure Yes Psychotic disorder No Unsure Yes
(schizophrenia or schizoaffective)
No Unsure Yes Bipolar disorder No Unsure Yes
No Unsure Ye Major depression No Unsure Yes
No Unsure Yes Anxiety disorder No Unsure Yes
No Unsure Yes Alcoholism No Unsure Yes
No Unsure Yes Prescription drug abuse No Unsure Yes
No Unsure Yes Illicit substance abuse No Unsure Yes
No Unsure Yes Criminality No Unsure Yes
No Unsure Yes Suicide No Unsure Yes
No Unsure Yes Suicide attempts No Unsure Yes
No Unsure Yes Eating disorder ' No Unsure Yes
No Unsure Yes Severe personality disorder No Unsure . Yes

(e.g., borderline, antisocial)

 

62. Finally, please indicate any history of psychiatric disorders in the patient’s ﬁrst- and second-
degree biological relatives (e.g., if biological mother, father, or any biological sibling has a
psychotic disorder, indicate “yes” for history of psychosis in ﬁrst-degree relatives). For these
ratings, be sure to include only biological relatives.

First Dggree Relatives Second Dggree Relatives
(biological mother, father, or sibling) (grandparent, aunt or uncle, niece or
nephew, half-sibling)
No Unsure Yes Psychotic disorder No Unsure Yes
(schizophrenia or schizoaffective)
No Unsure Yes Bipolar disorder No Unsure Yes
No Unsure Yes Major depression No Unsure Yes
No Unsure Yes Anxiety disorder No Unsure Yes
No Unsure Yes Alcoholism No Unsure Yes
No Unsure Yes Prescription drug abuse No Unsure Yes
No Unsure Yes Illicit substance abuse No Unsure Yes
No Unsure Yes Criminality No Unsure Yes
No Unsure Yes Suicide No Unsure Yes
No Unsure Yes Suicide attempts No Unsure Yes
No Unsure Yes Eating disorder No Unsure Yes
No Unsure Yes Severe personality disorder No Unsure Yes

(e.g., borderline, antisocial)

130

WN—

CLINICAL DATA FORM

ABOUT YOU (THE CLINICIAN)

 

. Discipline: Psychiatry Psychology
Sex: Female Male
. How would you describe your main theoretical orientation? (check one)
Biological Eclectic (If eclectic, please indicate approach that most informs
your work:)
Cognitive-Behavioral Biological Psychodynamic
Family Systems Cognitive-Behavioral Humanistic/experiential
Psychodynamic Family Systems Other eclectic
Humanistic/experiential Other
In what settings do you work? (check all that apply) Private practice
Clinic/hospital outpatient School Hospital inpatient/partial program
Residential facility Forensic Other

How many years of experience do you have post-training (i.e., post residency or licensure)? _

ABOUT THE PATIENT

DEMOGRAPHIC AND DIAGNOSTIC INFORMATION:

1.
2.
3.
4.

M

Age:
Sex: Female Male

Length of time in treatment with you (in months)

In what setting have you seen this patient? (check primary setting)

 

Private practice Outpatient clinic School
Hospital inpatient/partial program Residential facility Forensic Other
. Race/ethnicity: Caucasian African-American Hispanic Asian Other

. Global Assessment of Functioning (GAF) (referring to the 0-100 scale below, write a number

between 0 and 100 here, being as specific as you can):

10 30 50 7O 90 100
gross serious serious mild minimal
impairment/ impairment/ symptoms symptoms/ symptoms
psychotic psychotic recurrent problems
Socioeconomic status of family of origin (circle number):
1 2 3 4 5
poor working middle upper upper
class class middle class class
Education (circle number): 1 2 3 4 5
less than high some college graduate
high school school college education
. Marital Status: Married (ﬁrst marriage) Married (remarried)

Unmarried with long-term partner Divorced Separated
Single (never married) Widowed

131

10. Axis I diagnosis: Please read through the list below, and indicate whether the patient meets
DSM-I V criteria for each disorder. If you are unsure, check “No. ”

No Yes Major depressive disorder No Yes Dissociative disorder
No Yes Dysthymic disorder No Yes Somatoform disorder
(e.g.,hypochondriasis)

No Yes Bipolar disorder No Yes Sexual disorder

No Yes Cyclothymia or bipolar II No Yes Adjustment disorder

No Yes Other mood disorder (e.g., NOS) No Yes Anorexia, restricting type

No Yes Generalized anxiety disorder No Yes Anorexia, binge-purging type

No Yes Post-traumatic stress disorder No Yes Bulimia

No Yes Social phobia No Yes Other eating disorder (e.g., NOS)

No Yes Panic disorder No Yes Psychotic disorder

No Yes Obsessive-compulsive disorder No Yes Attention-deﬁcit/hyperactivity

disorder

No Yes Other anxiety disorder (e.g., No Yes Psychiatric disorder due to general
NOS) medical condition

No Yes Substance use disorder No Yes Other

 

l 1. Axis II diagnosis: Please read through the list below, and indicate whether the patient meets
DSM-I V criteria for each disorder. If you are unsure, check “No. ”

No Yes Paranoid No Yes Narcissistic

No Yes Schizoid No Yes Avoidant

No Yes Schizotypal No Yes Dependent

No Yes Antisocial No Yes Obsessive-compulsive
No Yes Borderline No Yes Personality disorder NOS

No Yes Histrionic

12. Chronic level of personality functioning (circle number):

1 2 3 4 5
severe substantial high-
personality disorder problems in living functioning
13. Quality of romantic relationships (circle number):
1 2 3 4 5
very poor/ loving &
unstable/absent stable
14. Quality of friendships (circle number):l 2 3 4 5
very poor/ close/
unable to maintain stable
15. Employment history (circle number): 1 2 3 4 5
unable working
to keep a job to full potential
16. Has the patient ever attempted suicide? No Yes
If “yes”: Rate the most severe suicide attempt (circle number):
1 2 3 4 5
mild (primarily moderate (required serious
symbolic gesture) medical attention) (life-threatening)
17. Has the patient ever self-mutilated? (excluding suicide attempts): No Yes
If “yes”: Describe the extent of the self-mutilation:
l 2 3 4 5
minor/superficial signiﬁcant
injury

18. Has the patient had psychiatric hospitalizations? No Yes

132

19. Has the patient been arrested in the last 5 years? No Yes

20. Has the patient committed a violent crime in the last 5 years? No Yes
21. Has the patient been raped or been the victim of a serious sexual assault in adulthood?
No Once More than once

22. Has the patient been in a physically abusive relationship as an adult? No Yes
If yes, was the patient primarily victim, perpetrator, or both (check both if both apply)?
victim perpetrator
23. Has the patient lost a job in the last 5 years because of interpersonal problems at work?
No Yes N/A
24. Approximately how many close current relationships has the patient described to you—people

in whom s/he feels comfortable conﬁding? None Very Few Some Many
25. Physical health (circle number): 1 2 3 4 5
serious or chronic or frequent few or occasional
degenerative illness illness that aﬂects health concerns

adaptive functioning
26. Approximately how often does the patient get minor illnesses such as the ﬂu, sore throats,
headaches, etc., that lead to missed appointments, days off work, visits to the doctor, or
subjective distress

1 2 3 4 5
rarely occasionally very frequently
(1 or 2 times a year) (a few times a year) (many times per year)

DEVELOPMENTAL AND FAMILY HISTORY:

Note: For Developmental and Family History items below, please check "no" if you are unsure,
unless given the response option "unsure" or "unclear.”

FAMILY ENVIRONMENT

 

 

27 . Patient was reared primarily by: both biological parents biological mother (with or without
step-father) biological father (with or without step-mother) adoptive parents foster parents
other

For the items that follow, if the patient has had more than one mother- or father-ﬁgure in
childhood, choose the person most involved in rearing the patient (who will usually be the person
the patient considers his/her mother or father). If the patient had no enduring relationship with
a mother- or father-ﬁgure as a child (e.g., if parents divorced early, father disappeared, and
the mother never remarried), circle N/A (not applicable).

Unless otherwise specified, describe the patient ’s childhood experience through age 16.
In cases in which the family environment changed dramatically at some point and
remained that way for several years, rate what you consider the most psychologically
significant period.

28. Relationship with mother as a child (circle number or N/A):

N/A 1 2 3 4 5
poor/ positive/
conflictual loving

29. Relationship with father as a child (circle number or N/A):

N/A 1 2 3 4 5
poor/ positive/
conﬂictual loving

133

30. Mother’s psychological functioning (circle number or N/A):
N/A 1 2 3 4 5
psychotic personality disorder/ hi-ﬁmctioning
Severe recurrent Axis I
31. Father’s psychological functioning (circle number or N/A):
N/A 1 2 3 4 5
psychotic personality disorder/ iii-functioning
severe recurrent Axis I
32. Lengthy traumatic separations from primary caregiver for more than 6 weeks:

No Yes age 1-6 Yes, age 7-12 Yes, age 13-16
1'" “.yes ’9'.
To what extent did the patient experience the separation(s) as traumatic (circle number):
1 2 3 4 5
not at all moderately very
Frequency of separations (circle number):
1 2 3 4 5

once infrequently periodically ﬁ'equently permanently
33. Parental divorce/permanent separation during childhood:

No Yes age 1-6 Yes, age 7-12 Yes, age 13-16 N/A (e.g., never lived
with both parents)
34. Mother died during patient’s childhood:
No Yes age 1-6 Yes, age 7-12 Yes, age 13-16
35. Father died during patient’s childhood:
No Yes age 1-6 Yes, age 7-12 Yes, age 13-16
36. Describe the stability of the primary caregiver’s sexual/romantic relationships (circle number or
N/A): N/A 1 2 3 4 5
monogamous/ somewhat unstable/ multiple/
stable changing indiscriminate partners
37. Was the patient ever in foster care as a child? No Yes

If “yes”: Approximately how many placements was the patient in?

38. Was the patient ever sent to live with other family members or friends because of parental
difficulties providing a stable home life? No Yes
39. Were the parents or family ever investigated for child mistreatment or neglect? No Yes
40. Did the patient have an alcoholic parent or step-parent living in the home for a substantial
period of time when s/he was a child or adolescent? No Yes
41. Was the patient’s mother sexually abused as a child?: No Unsure Yes
42. Approximate number of residence changes (family moves) in patient’s childhood, other than
those due to parental job transfers: 0-1 2-3 4-6 >6
43. Rate the extent to which the family environment was predictable, stable, and consistent (circle
number): 1 2 3 4 5
chaotic predictable/consistent

44. Rate the extent to which the family environment was warm and nurturing (circle number):

1 2 3 4 5
cold/hostile warm/n urturing

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45. Did the patient have someone (other than a parent) s/he could consistently turn to for emotional
support during difﬁcult times in childhood (e.g., grandparent, family friend, teacher)? No
Yes

 

 

PHYSICAL & SEXUAL ABUSE
46. Was the patient physically abused as a child? No Unclear Yes (approximate age at
ﬁrst abuse: )
If “yes” (circle numbers):

Severity of physical abuse: 1 2 3 4 5
no physical injury bruises, welts broken
. bones, burns, etc.
Frequency of physical abuse: 1 2 3 4 5
once periodic weekly or more
47. Did the patient witness domestic violence as a child? No Unclear Yes
48. Was the patient sexually abused as a child? No Unclear Yes (approximate age at
ﬁrst abuse: )
If “yes ’9:
Severity of sexual abuse: (circle number): 1 2 3 4 5
non-contact oral sex penetration
exposure, kissing
Degree of force used (circle number): 1 2 3 4 5
minimal verbal coercion physical
violence/coercion
Frequency of sexual abuse (circle number): 1 2 3 4 5
once periodic weekly

Main perpetrator of sexual abuse (choose one): father step-father/mother’s lover
mother brother other relative non-relative

Approximate total number of perpetrators:

Did the patient disclose the sexual abuse to parent(s) as a child/adolescent? No Yes

If “yes”: How did parent(s) respond to the disclosure? (circle number):

1 2 3 4 5
denied abuse/ supportive,
blamed child accepting, help-seeking

CHILD/ADOLESCENT BEHAVIOR

 

 

49. Was the patient enuretic as a child (bed-wetting)? No Yes
50. Did the patient engage in ﬁre-setting as a child/adolescent? No Yes
51. Did the patient torture animals as a child/adolescent? No Yes

52. Did the patient run away from home as a child/adolescent? (circle number):

1 2 3 4 5
no a few times frequently

53. Did the patient abuse alcohol or other illegal substances as a child/adolescent? No Yes
(age began: _ )

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54. Did the patient initiate physical ﬁghts with peers as a child/adolescent?
No Yes (age began: )

55. Did the patient have problems with discipline, truancy, suspensions, etc., at school?
No Yes (age began: _ )

56. General performance in school (circle number): 1 2 3 4 5
failed/ passing high
dropped out grades achievement

57. Did the patient get in trouble for chronic lying as a child/adolescent?

No Yes (age began: _ )
58. Did the patient engage in frequent stealing as a child/adolescent?

No Yes (age began: _ )
59. Did the patient commit violent or armed crimes as a child/adolescent?

No Yes (age began: )
60. Was the patient ever arrested as a child/adolescent? (circle number):
1 2 3 4 5
no a few times frequently

61. At approximately what age did the patient ﬁrst have sexual intercourse (excluding sexual
abuse)? N/A
62. Did the patient engage in promiscuous sex as a child/adolescent? No Yes (age
began: )
63. Did the patient have close friends as a child/adolescent? No Very Few Some
Many
64. Was the patient ever evaluated or treated by a mental health professional as a child/adolescent?
No Yes
If “yes”: What was the patient’s approximate age at ﬁrst mental health contact:

 

“PARENTAL PSYCHOPATHOLOGY AND FAMILY PSYCHIATRIC HISTORY—-
Please do not leave any of the following questions blank. If you do not know, or if the data are
unclear, please mark “Unsure. ”

65. Please indicate any history of psychiatric disorders in the patient’s mother or father (or mother-
or father-ﬁgure, in cases in which the primary parental ﬁgures were not the biological parents).

Mother Father
No Unsure Yes Psychotic disorder No Unsure Yes
(schizophrenia or schizoaffective)
No Unsure Yes Bipolar disorder No Unsure Yes
No Unsure Yes Major depression No Unsure Yes
No Unsure Yes Anxiety disorder No Unsure Yes
No Unsure Yes Alcoholism No Unsure Yes
No Unsure Yes Prescription drug abuse No Unsure Yes
No Unsure Yes Illicit substance abuse No . Unsure Yes
No Unsure Yes Criminality No Unsure Yes
No Unsure Yes Suicide No Unsure Yes
No Unsure Yes Suicide attempts No Unsure Yes
No Unsure Yes Eating disorder No Unsure Yes
No Unsure Yes Severe personality disorder No Unsure Yes

(e.g., borderline, antisocial)

136

 

66. Now, please indicate any history of psychiatric disorders in the patient’s ﬁrst- and second-degree
biological relatives (e.g., if biological mother, father, or any biological sibling has a psychotic
disorder, indicate “yes” for history of psychosis in ﬁrsbdegree relatives). For these ratings, be sure
to include only biological relatives.

First Dggree Relatives Second Mme Relatives
(biological mother, father, or sibling) (grandparent, aunt or uncle, niece or

nephew, half-sibling)

No Unsure Yes Psychotic disorder No Unsure Yes
(schizophrenia or schizoafl'ective)
No Unsure Yes Bipolar disorder No Unsure Yes
No Unsure Yes Major depression No Unsure Yes
No Unsure Yes Anxiety disorder No Unsure Yes
No Unsure Yes Alcoholism No Unsure Yes
No Unsure Yes Prescription drug abuse No Unsure Yes
No Unsure Yes Illicit substance abuse No Unsure Yes
No Unsure Yes Criminality No Unsure Yes
No Unsure Yes Suicide No Unsure Yes
No Unsure Yes Suicide attempts No Unsure Yes
No Unsure Yes Eating disorder No Unsure Yes
No Unsure Yes Severe personality disorder No Unsure Yes

(e.g., borderline, antisocial)
EFFECTIVENESS OF TREATMENT:

67. Has the patient been in psychotherapy with you? No Yes
If “yes,” how effective has psychotherapy been to date? (i. e., how much change or benefit)

N/A (began recently) 1 2 3 4 5
not at all somewhat highly

68. Has the patient taken psychotropic medication at any time during treatment with you? No
Yes

If “yes”, please check all medication categories that apply. If you know the specific drug(s),
please indicate this by checking the appropriate box(es). (If more than one drug was tried,
please check all applicable).

Antidepressants
SSRI (e.g., Prozac, Paxil, Zoloft, Celexa)
Tricyclic (e.g., Elavil, Anafranil, Norpramin, Tofranil, Pamelor)
MAO inhibitor (e.g., Nardil, Eldepryl, Parnate)
Other antidepressant (e.g., Effexor, Wellbutrin, Remeron, Serzone)
How effective was the medication? (If more than one used, rate the most effective one)

1 2 3 4 5
not at all, somewhat highly,
or intolerable side effects controlled all or
most symptoms

Anxiolytics (anti-anxiety)

Buspar
Benzodiazepine (e.g., Xanax, Valium, Librium, Ativan, Klonopin)

137

 

 

How effective was the medication? (If more than one used, rate the most effective one)

1 2 3 4 5
not at all, somewhat highly,
or intolerable side effects controlled all or
most symptoms

Mood stabilizers (e.g., Lithium, Tegretol, Depakote, Lamictal, Neurontin)

How effective was the medication? (If more than one used, rate the most effective one)

1 2 3 4 5
not at all, somewhat highly,
or intolerable side effects controlled all or

most symptoms

Antipsychotics (e.g., Haldol, Thorazine, Prolixin, Zyprexa)

How effective was the medication? (If more than one used, rate the most effective one)

1 2 3 4 5
not at all, somewhat highly,
or intolerable side effects controlled all or
most symptoms

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11

12

13

14

15

16

17

18

SWAP-II-A
Tends to feel guilty (e.g., may blame self or feel responsible for bad
things that happen).
Is able to use his/her talents, abilities, and energy effectively and
productively.
Takes advantage of others; has little investment in moral values (e.g., puts
own needs ﬁrst, uses or exploits people with little regard for their feelings
or welfare, etc.).
Has an exaggerated sense of self-importance (e. g., feels special, superior,
grand; believes s/he is the object of envy; tends to boast or brag).
Tends to be ignored, neglected, or avoided by peers.
Is troubled by recurrent obsessional thoughts that s/he experiences as
intrusive.
Appears conﬂicted about his/her racial or ethnic identity (e.g.,
undervalues and rejects, or overvalues and is preoccupied with, own
cultural heritage).
Seems childish for his/her age (e.g., acts like a younger child or primarily
chooses younger peers).
When upset, has trouble perceiving both positive and negative qualities in
the same person at the same time (e.g., may see others in black or white
terms, shiﬁ suddenly from seeing someone as caring to seeing him/her as
malevolent and intentionally hurtful, etc.).
Is preoccupied with aggressive games, fantasies, ﬁrearms, etc.
Tends to become attached quickly or intensely; develops feelings,
expectations, etc. that are not warranted by the history or context of the
relationship.
Emotions tend to spiral out of control, leading to extremes of anxiety,
sadness, rage, etc.
Tends to use his/her psychological or medical problems to avoid school,
work, or responsibility (whether consciously or unconsciously).
Tends to blame own failures or shortcomings on other people or
circumstances; attributes his/her difﬁculties to external factors rather than
accepting responsibility for own conduct or choices.
Lacks a stable sense of who s/he is (e.g., attitudes, values, goals, and
feelings about self seem unstable or ever-changing).
Tends to be angry or hostile (whether consciously or unconsciously).
Tends to be ingratiating or submissive with peers (e.g., may consent to
things s/he does not agree with or does not want to do, in the hope of
getting support or approval).
Tends to stir up conﬂict or animosity between other people (e. g., may
portray a situation differently to different people, leading them to form
contradictory views or work at cross purposes).

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21
22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

Enjoys challenges; takes pleasure in accomplishing things.

Tends to be deceitful; tends to lie or mislead.

Tends to be hostile toward members of the opposite sex, whether
consciously or unconsciously (e.g., may be disparaging or competitive).
Tends to develop somatic symptoms in response to stress or conﬂict (e.g.,
headache, backache, abdominal pain, asthma, etc.).

Tends to get involved in romantic or sexual “triangles” (e.g., becomes
interested in people who are already attached, sought by someone else,
etc.).

Tends to be unreliable and irresponsible (e.g., may fail to meet school or
work obligations).

Has difﬁculty acknowledging or expressing anger.

Tends to get drawn into relationships outside the family in which s/he is
emotionally or physically abused, or needlessly puts self in dangerous
situations (e.g., walking alone or meeting strangers in unsafe places).
Has panic attacks (i.e., episodes of acute anxiety accompanied by strong
physiological responses).

Tends to be preoccupied with concerns about dirt, cleanliness,
contamination, etc. (e.g., drinking from another person’s glass, sitting on
public toilet seats, etc.).

Has difﬁculty making sense of other people’s behavior; tends to
misunderstand, misinterpret, or be confused by others’ actions and
reactions.

Tends to feel listless, fatigued, or lacking in energy.

Tends to show reckless disregard for the rights, property, or safety of
others.

Is capable of sustaining meaningful relationships characterized by
genuine intimacy and caring.

Is conﬂicted or inhibited about achievement or success (e. g.,
achievements may be below potential, may sabotage self just before
attaining important goals, etc.).

Tends to be sexually seductive or provocative (e.g., may be
inappropriately ﬂirtatious, preoccupied with sexual conquest, prone to use
his/her physical attractiveness to an excessive degree to gain notice).
Tends to feel anxious.

Tends to feel helpless, powerless, or at the mercy of forces outside his/her
control (beyond what is warranted by the situation).

Finds meaning in belonging and contributing to a larger community (e. g.,
volunteer organizations, teams, neighborhood groups, church, etc.).
Tends to feel s/he is not his/her true self with others; may feel false or
fraudulent.

Appears to gain pleasure or satisfaction by being sadistic or aggressive
(whether consciously or unconsciously) or bullying others.

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40
41
' 42
43
44

45

46
47

43
49

50
51
52

53
54
55
56
57
58
59
6O
61

62
63
64

Tends to engage in criminal or delinquent behavior (moderate placement
of this item implies occasional or petty crimes such as shoplifting or
vandalism).

Appears unable to describe important others in a way that conveys a sense
of who they are as people; descriptions of others come across as two-
dimensional and lacking in richness.

Tends to feel envious.

Tends to seek power or inﬂuence with peers (whether in beneﬁcial or
destructive ways).

When distressed, perception of reality can become grossly impaired (e. g.,
thinking may seem delusional).

Is prone to idealizing people; may see admired others as perfect, larger
than life, all wise, etc.

Tends to be suggestible or easily inﬂuenced.

Attempts to avoid or ﬂee depressive feelings through excessive optimism,
activity, energy, etc.

Seeks to be the center of attention.

When distressed, tends to revert to earlier, less mature ways of coping
(e.g., clinging, whining, having tantrums).

Tends to feel life has no meaning.

Tends to be liked by other people.

Has little empathy; seems unable or unwilling to understand or respond to
others’ needs or feelings.

Seems to treat others primarily as an audience to witness own importance,
brilliance, beauty, etc.

Tends to feel s/he is inadequate, inferior, or a failure.

Finds meaning and fulﬁllment in guiding, mentoring, or nurturing others.
Appears to ﬁnd little or no pleasure, satisfaction, or enjoyment in life’s
activities.

Religious or spiritual beliefs are central to his/her identity and experience.
Has little or no interest in sexuality (e.g., does not engage in age-
appropriate fantasy, exploration, or experimentation, or shows little
curiosity).

Is empathic; is sensitive and responsive to other peoples’ needs and
feelings.

Tends to be shy or self-conscious in social situations.

Tends to disparage qualities traditionally associated with own gender
(e.g., a girl who disdains nurturance and overvalues power; a boy who
disdains power and overvalues emotional sensitivity).

Tends to be preoccupied with food, diet, or eating.

Is able to assert him/herself effectively and appropriately when necessary.
Mood tends to cycle over intervals of weeks or months between excited
and depressed states (high placement implies bipolar mood disorder).

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66
67
68
69
70
71
72
73

74
75

76

77

78

79

80

81

82

83

84

85

86

87
88

Attempts to control or dominate a signiﬁcant other (e. g., sibling, parent,
boyfriend, girlfriend) through violence or intimidation.

Is excessively devoted to school, work, or productivity, to the detriment
of fun, pleasure, or friendships.

Tends to be stingy and withholding (of time, money, affection, etc.).

Has a good sense of humor.

Decisions and actions are unduly inﬂuenced by efforts to avoid perceived
dangers; is more concerned with avoiding harm than pm'suing desires.
Has uncontrolled eating binges followed by “purges” (e.g., makes self
vomit, abuses laxatives, fasts, etc.); has bulimic episodes.

Tends to seek thrills, novelty, excitement, etc.; appears to require a high
level of stimulation.

Tends to perceive things in global and impressionistic ways (e.g., misses
details, glosses over inconsistencies, mispronounces names).

Tends to “catastrophize”; is prone to see problems as disastrous,
unsolvable, etc.

Expresses emotion in exaggerated and theatrical ways.

Tends to think in concrete terms and interpret things in overly literal
ways; has limited ability to appreciate metaphor, analogy, or nuance.
Manages to elicit in others feelings similar to those s/he is experiencing
(e. g., when angry, acts in such a way as to provoke anger in others; when
anxious, acts in such a way as to induce anxiety in others).

Tends to be needy or dependent.

Tends to express anger in passive and indirect ways (e.g., may make
mistakes, procrastinate, forget, become sulky, etc.).

Attempts to deny or “override” fear or anxiety by rushing headlong into
feared situations, taking unnecessary risks, etc.

Tends to be bullied, harassed, or teased by peers.

Repeatedly re-experiences or re-lives a past traumatic event (e.g., has
intrusive memories or recurring dreams of the event; is startled or terriﬁed
by present events that resemble or symbolize the past event).

Derives satisfaction or self-esteem from being, or being seen as, “bad” or
“tough.”

Beliefs and expectations seem cliché or stereotypical, as if taken from
storybooks or movies.

Tends to be competitive with others (whether consciously or
unconsciously).

Has conscious homosexual desires (moderate placement implies
bisexuality, high placement implies homosexuality).

Tends to feel ashamed or embarrassed.

Tends to run away from home.

Tends to be insufﬁciently concerned with meeting own needs; appears not
to feel entitled to get or ask for things s/he deserves.

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93
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95
96
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100

101
102

103

104

105

106

107

108

109

110

111

Is resilient in the face of stress; seems to be able to face loss, trauma, or
deeply troubling events with appropriate feeling and to continue to
function effectively.

Is prone to painful feelings of emptiness (e.g., may feel lost, bereft,
abjectly alone even in the presence of others, etc.).

Is self-critical; sets unrealistically high standards for self and is intolerant
of own human defects.

Is articulate; can express self well in words.

Seems na'r've or innocent; appears to know less about the ways of the
world than might be expected given his/her age, intelligence, or
background.

Tends to surround him/herself with peers who are delinquent or deeply
alienated.

Appears comfortable and at ease in social situations.

Tends to elicit dislike or animosity in others.

Has trouble sitting still; is restless, ﬁdgety, or hyperactive.

Tends to fear s/he will be rejected or abandoned.

Is unduly ﬁightened by sexuality; appears to associate sex with danger
(e.g., injury, punishment, contamination).

Tends to think in abstract and intellectualized terms, even in matters of
personal import.

Generally ﬁnds contentment and happiness in life’s activities.

Has a deep sense of inner badness; sees self as damaged, evil, or rotten to
the core (whether consciously or unconsciously).

Tends to have extreme reactions to perceived slights or criticism (e.g.,
may react with rage, humiliation, etc.).

Appears to have little need for human company or contact; is emotionally
detached or indifferent.

Is suspicious; tends to assume others will harm, deceive, conspire against,
or betray him/her.

Tends to express emotion appropriate in quality and intensity to the
situation at hand.

Tends to express qualities or mannerisms traditionally associated with
own gender to an exaggerated or stereotypical degree (i.e., a hyper-
feminine girl; a hyper-masculine, “macho” boy).

Tends to restrict food intake to the point of being underweight and
malnourished.

Tends to engage in self-mutilating behavior (e.g., self-cutting, self-
buming, etc.).

Tends to become attached to, or romantically interested in, people who
are emotionally unavailable.

Has the capacity to recognize alternative viewpoints, even in matters that
stir up strong feelings.

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136

Appears impervious to consequences; seems unable or unwilling to
modify behavior in response to threats or negative consequences.
Experiences little or no remorse for harm or injury caused to others.
Tends to be critical of others.

Is prone to violence (e.g., may break things, provoke ﬁghts, or become
physically assaultive).

Tends to see own unacceptable feelings or impulses in other people
instead of in him/herself.

Is unable to soothe or comfort him/herself without the help of another
person (i.e., has difﬁculty regulating own emotions).

Has difﬁculty maintaining attention and focus on tasks; is easily
distracted by sights, sounds, unrelated thoughts, or other competing
stimuli.

Tends to be inhibited or constricted; has difﬁculty allowing self to
acknowledge or express wishes and impulses.

Has moral and ethical standards and strives to live up to them.

Is creative; is able to see things or approach problems in novel ways.
Attempts to avoid feeling helpless or depressed by becoming angry
instead.

Tends to adhere rigidly to daily routines and become anxious or
uncomfortable when they are altered.

Tends to avoid, or try to avoid, social situations because of fear of
embarrassment or humiliation.

Appearance or manner seems odd or peculiar (e.g., grooming, hygiene,
posture, eye contact, speech rhythms, etc. seem somehow strange or
“off”).

Appears to have a limited or constricted range of emotions.

Tends to feel misunderstood, mistreated, or victimized.

Fantasizes about ideal, perfect love.

Tends to be overly compliant or obedient with authority ﬁgures.
Reasoning processes or perceptual experiences seem odd and
idiosyncratic (e.g., may make seemingly arbitrary inferences; may see
hidden messages or special meanings in ordinary events).

Appears conﬂicted about experiencing pleasurable emotions; tends to
inhibit excitement, joy, pride, etc.

Is sexually promiscuous for a person of his/her age, background, etc.
Tends to be dismissive, haughty, or arrogant.

Tends to act impulsively (e.g., acts without forethought or concern for
consequences).

Is hypochondriacal; has exaggerated fears of contracting medical ilhress
(e.g., worries excessively about normal aches and pains).

Tends to believe in supernatural, paranormal, or superstitious phenomena
or to be drawn to “alternative” belief systems (e.g., astrology, tarot,

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crystals, psychics, auras).

Is confused, conﬂicted, or uncertain about his/her sexual orientation (e.g.,
may struggle to keep homosexual feelings out of awareness, have an
exaggerated fear of homosexuality, etc.).

Tends to enter altered, dissociated states when distressed (e.g., the self or
world feels strange, unreal, or unfamiliar).

Tends to hold grudges; may dwell on insults or slights for long periods.
Sexual fantasies or activities are unusual, idiosyncratic, or rigidly scripted
(e.g., dominance, submission, voyeurism, fetishes, etc.).

Is invested in seeing and portraying self as emotionally strong,
untroubled, and emotionally in control, despite clear evidence of
underlying insecurity, anxiety, or distress.

Tends to make repeated suicidal threats or gestures, either as a “cry for
help” or as an effort to manipulate others.

Tends to believe s/he can only be appreciated by, or should only associate
with, people who are high-status, superior, or otherwise “special.”

Tends to see self as logical and rational, uninﬂuenced by emotion; prefers
to operate as if emotions were irrelevant or inconsequential.

Thought processes or speech tend to be circumstantial, vague, rambling,
digressive, etc. (e.g., may be unclear whether s/he is being metaphorical
or whether thinking is confused or peculiar).

Tends to elicit boredom in others (e.g., may talk incessantly, without
feeling, or about inconsequential matters).

Tends to abuse alcohol or drugs (beyond what is normative given his/her
age, background, etc.).

Has little psychological insight into own motives, behavior, etc.

Tends to feel like an outcast or outsider.

Tends to identify with admired others to an exaggerated degree, taking on
their attitudes, mannerisms, etc., in a way that is not normative for his/her
age, background, etc.

Appears to experience the past as a series of disjointed or disconnected
events; has difﬁculty giving a coherent account of his/her life or actions.
Tends to repress or “forget” distressing events, or distort memories of
distressing events beyond recognition.

Relationships tend to be unstable, chaotic, and rapidly changing.

Tends to draw others into scenarios, or “pull” them into roles, that feel
alien or unfamiliar (e. g., being uncharacteristically insensitive or cruel,
feeling like the only person in the world who can help, etc.).

Tends to describe experiences in generalities; is reluctant to provide
details, examples, or supporting narrative.

Has a disturbed or distorted body-image (e.g., may see self as
unattractive, grotesque, disgusting, etc.)

Tends to become irrational when strong emotions are stirred up; may

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show a signiﬁcant decline from customary level of functioning.

Has areas of accomplishment or achievement other than school (e. g.,
sports, music, etc.) for which s/he gains considerable recognition.

Tends to deny or disavow own need for nurturance, caring, comfort, etc.
(e.g., may regard such needs as weakness, avoid depending on others or
asking for help, etc.)

Lacks close friendships and relationships.

Tends to deny, disavow, or squelch his/her own realistic hopes, dreams, or
desires to protect against anticipated disappointment (whether consciously
or unconsciously).

Expresses contradictory feelings or beliefs without being disturbed by the
inconsistency; has little need to reconcile or resolve contradictory ideas.
Appears to want to “punish” self; creates situations that lead to
unhappiness, or actively avoids opportunities for pleasure and
gratiﬁcation.

Tends to be self-righteous or moralistic.

Tends to distort unacceptable wishes or feelings by transforming them
into their opposite (e.g., may express excessive concern while showing
signs of unacknowledged hostility, disgust about sexual matters while
showing signs of unacknowledged excitement, etc.).

Tends to alternate between undercontrol and overcontrol of needs and
impulses (e.g., sometimes acts on desires impulsively while at other times
denying them entirely).

Is simultaneously needy of, and rejecting toward, others (e.g., craves
intimacy and caring, but tends to reject it when offered).

Struggles with genuine wishes to kill him/herself.

Fears becoming like a parent (or parent ﬁgure) about whom s/he has
strong negative feelings.

Is rebellious or deﬁant toward authority ﬁgures; tends to be oppositional,
contrary, quick to disagree, etc.

Appears to fear being alone; may go to great lengths to avoid being alone.
Tends to give up quickly when frustrated or challenged.

Tends to become absorbed in details, often to the point that s/he misses
what is signiﬁcant.

Expects self to be “perfect” (e.g., in appearance, achievements,
performance, etc.).

Tends to be conscientious and responsible.

Tends to confuse own thoughts, feelings, or personality traits with those
of others (e.g., may use the same words to describe him/herself and
another person, believe the two share identical thoughts and feelings,
etc.).

Repeatedly convinces others of his/her commitment to change but then
reverts to previous maladaptive behavior; tends to convince others that

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“this time is really different.”

Tends to feel bored.

Tends to be energetic and outgoing.

Has trouble making decisions; tends to be indecisive or to vacillate when
faced with choices.

Tends to choose sexual or romantic partners who seem inappropriate in
terms of age, status (e.g., social, economic, intellectual), etc.

Tends to be controlling.

Is psychologically insightful; is able to understand self and others in
subtle and sophisticated ways.

Verbal statements seem incongruous with accompanying affect, or
incongruous with accompanying non-verbal messages.

Is prone to intense anger, out of proportion to the situation at hand (e. g.,
has rage episodes).

Seems preoccupied with sex or sexuality, in a way that is not normative
for his/her age (e.g., makes constant sexualized comments, masturbates
compulsively, etc.).

Tends to feel guilty or ashamed about his/her sexual interests or activities
(whether consciously or unconsciously).

Has difﬁculty separating from a parent (e.g., fears something terrible will
happen to the parent if s/he leaves, resists going to school, cannot spend
the night away from home).

Tends to feel unhappy, depressed, or despondent.

Appears to feel privileged and entitled; expects preferential treatment.
Emotions tend to change rapidly and unpredictably.

Tends to be overly concerned with rules, procedures, order, organization,
schedules, etc.

Lacks social skills; tends to be socially awkward or inappropriate.

Tends to be manipulative.

Tends to be preoccupied with death and dying.

Finds meaning and satisfaction in the pursuit of long-term goals and
ambitions.

Tends to seek out or create interpersonal relationships in which s/he is in
the role of caring for, rescuing, or protecting the other.

Has trouble acknowledging or expressing anger toward others, and
instead becomes depressed, self-critical, self-punitive, etc. (i.e., turns
anger against self).

Tends to be passive and unassertive.

Tends to ruminate; may dwell on problems, replay conversations in
his/her mind, become preoccupied with thoughts about what could have
been, etc.

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SWAP-II
Tends to feel guilty (e.g., may blame self or feel responsible for bad things that
happen).
Is able to use his/her talents, abilities, and energy effectively and productively.
Takes advantage of others; has little investment in moral values (e. g., puts own
needs ﬁrst, uses or exploits people with little regard for their feelings or welfare,
etc.).
Has an exaggerated sense of self-importance (e.g., feels special, superior, grand,
or envied).
Tends to be emotionally intrusive (e. g., may not respect other people’s needs for
autonomy, privacy, etc.).
Is troubled by recurrent obsessional thoughts that s/he experiences as intrusive.
Appears conﬂicted about his/her racial or ethnic identity (e. g., undervalues and
rejects, or overvalues and is preoccupied with, own cultural heritage).
Tends to get into power struggles.
When upset, has trouble perceiving both positive and negative qualities in the
same person at the same time (e.g., may see others in black or white terms, shift
suddenly from seeing someone as caring to seeing him/her as malevolent and
intentionally hurtful, etc.).
Believes that some important other has a special, seemingly magical ability to
know his/her innermost thoughts or feelings (e. g., imagines rapport is so perfect
that ordinary communication is superﬂuous).
Tends to become attached quickly or intensely; develops feelings, expectations,
etc. that are not warranted by the history or context of the relationship.
Emotions tend to spiral out of control, leading to extremes of anxiety, sadness,
rage, etc.
Tends to use his/her psychological or medical problems to avoid work or
responsibility (whether consciously or unconsciously).
Tends to blame own failures or shortcomings on other people or
circmnstances; attributes his/her difficulties to external factors rather than
accepting responsibility for own conduct or choices.
Lacks a stable sense of who s/he is (e.g., attitudes, values, goals, and feelings
about self seem unstable or ever-changing).
Tends to be angry or hostile (whether consciously or unconsciously).
Tends to be ingratiating or submissive (e. g., consents to things s/he does not want
to do, in the hope of getting support or approval).
Tends to stir up conﬂict or animosity between other people (e. g., may portray a
situation differently to different people, leading them to form contradictory views
or work at cross purposes).
Enjoys challenges; takes pleasure in accomplishing things.
Tends to be deceitful; tends to lie or mislead.

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Tends to be hostile toward members of the opposite sex, whether consciously or
unconsciously (e.g., may be disparaging or competitive).

Tends to develop somatic symptoms in response to stress or conﬂict (e. g.,
headache, backache, abdominal pain, asthma, etc.).

Tends to become involved in romantic or sexual “triangles” (e. g., is drawn to
people who are already attached, sought by someone else, etc.).

Tends to be unreliable and irresponsible (e.g., may fail to meet work obligations
or honor ﬁnancial commitments).

Has difﬁculty acknowledging or expressing anger.

Tends to get drawn into or remain in relationships in which s/he is emotionally or
physically abused, or needlessly puts self in dangerous situations (e. g., walking
alone or agreeing to meet strangers in unsafe places).

Has panic attacks (i.e., episodes of acute anxiety accompanied by strong
physiological responses).

Tends to be preoccupied with concerns about dirt, cleanliness, contamination, etc.
(e.g., drinking from another person’s glass, sitting on public toilet seats, etc.).
Has difﬁculty making sense of other people’s behavior; tends to misunderstand,
misinterpret, or be confused by others’ actions and reactions.

Tends to feel listless, fatigued, or lacking in energy.

Tends to show reckless disregard for the rights, property, or safety of others.

Is capable of sustaining meaningful relationships characterized by genuine
intimacy and caring.

Is conﬂicted or inhibited about achievement or success (e.g., achievements may
be below potential, may sabotage self just before attaining important goals, etc.).
Tends to be sexually seductive or provocative (e. g., may be inappropriately
ﬂirtatious, preoccupied with sexual conquest, prone to “lead people on,” etc.).
Tends to feel anxious.

Tends to feel helpless, powerless, or at the mercy of forces outside his/her control.
Finds meaning in belonging and contributing to a larger community (e.g.,
organization, neighborhood, church).

Tends to feel s/he is not his/her true self with others; may feel false or fraudulent.
Appears to gain pleasure or satisfaction by being sadistic or aggressive toward
others (whether consciously or unconsciously).

Tends to engage in unlawful or criminal behavior.

Appears unable to describe important others in a way that conveys a sense of who
they are as people; descriptions of others come across as two-dimensional and
lacking in richness.

Tends to feel envious.

Tends to seek power or inﬂuence over others (whether in beneﬁcial or destructive
ways).

When distressed, perception of reality can become grossly impaired (e.g., thinking

may seem delusional).
Is prone to idealizing people; may see admired others as perfect, larger than life,

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all wise, etc.

Tends to be suggestible or easily inﬂuenced.

Attempts to avoid or ﬂee depressive feelings through excessive optimism,
activity, energy, etc.

Seeks to be the center of attention.

Has fantasies of unlimited success, power, beauty, talent, brilliance, etc.

Tends to feel life has no meaning.

Tends to be liked by other people.

Has little empathy; seems unable or unwilling to understand or respond to others
needs or feelings.

Seems to treat others primarily as an audience to witness own importance,
brilliance, beauty, etc.

Tends to feel s/he is inadequate, inferior, or a failure.

Finds meaning and fulﬁllment in guiding, mentoring, or nurturing others.
Appears to ﬁnd little or no pleasure, satisfaction, or enjoyment in life’s activities.
Religious or spiritual beliefs are central to his/her identity and experience.

Has little or no interest in sex.

Is empathic; is sensitive and responsive to other pe0ples’ needs and feelings.
Tends to be shy or self-conscious in social situations.

Tends to disparage qualities traditionally associated with own gender (e.g., a
woman who disdains nurturance and overvalues power; a man who disdains
power and overvalues emotional sensitivity).

Tends to be preoccupied with food, diet, or eating.

Is able to assert him/herself effectively and appropriately when necessary.
Mood tends to cycle over intervals of weeks or months between excited and
depressed states (high placement implies bipolar mood disorder).

Attempts to dominate a signiﬁcant other (e. g., spouse, lover, family member)
through violence or intimidation.

Is excessively devoted to work and productivity to the detriment of leisure and
relationships.

Tends to be stingy and withholding (e.g., of time, money, affection, ideas).

Has a good sense of humor.

Decisions and actions are unduly inﬂuenced by efforts to avoid perceived
dangers; is more concerned with avoiding harm than pursuing desires.

Has uncontrolled eating binges followed by “purges” (e.g., makes self vomit,
abuses laxatives, fasts, etc.); has bulimic episodes.

Tends to seek thrills, novelty, excitement, etc.; appears to require a high level of
stimulation.

Tends to perceive things in global and impressionistic ways (e.g., misses details,
glosses over inconsistencies, mispronounces names).

Tends to “catastrophize”; is prone to see problems as disastrous, unsolvable, etc.
Expresses emotion in exaggerated and theatrical ways.

Tends to think in concrete terms and interpret things in overly literal ways; has

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limited ability to appreciate metaphor, analogy, or nuance.

Manages to elicit in others feelings similar to those s/he is experiencing (e.g.,
when angry, acts in such a way as to provoke anger in others; when anxious, acts
in such a way as to induce anxiety in others).

Tends to be needy or dependent.

Tends to express anger in passive and indirect ways (e.g., may make mistakes,
procrastinate, forget, become sulky, etc.).

Attempts to deny or “override” fear or anxiety by rushing headlong into feared
situations, taking unnecessary risks, etc.

Tends to be sexually possessive or jealous; is preoccupied with concerns about
real or imagined inﬁdelity.

Repeatedly re-experiences or re-lives a past traumatic event (e.g., has intrusive
memories or recurring dreams of the event; is startled or terriﬁed by present
events that resemble or symbolize the past event).

Is capable of hearing information that is emotionally threatening (i.e., that
challenges cherished beliefs, perceptions, and self-perceptions) and can use and
beneﬁt from it.

Beliefs and expectations seem cliché or stereotypical, as if taken from storybooks
or movies.

Tends to be competitive with others (whether consciously or unconsciously).
Has conscious homosexual desires (moderate placement implies bisexuality, high
placement implies homosexuality).

Tends to feel ashamed or embarrassed.

Sense of identity revolves around a “cause,” movement, or label (e.g., adult child
of alcoholic, adult survivor, environmentalist, bom—again Christian, etc.); may be
drawn to extreme or all-encompassing belief systems.

Tends to be insufﬁciently concerned with meeting own needs; appears not to feel
entitled to get or ask for things s/he deserves.

Appears to have come to terms with painful experiences from the past; has found
meaning in, and grown from such experiences.

Is prone to painful feelings of emptiness (e.g., may feel lost, bereft, abjectly alone
even in the presence of others, etc.).

Is self-critical; sets unrealistically high standards for self and is intolerant of own
human defects.

Is articulate; can express self well in words.

Seems naive or innocent; appears to know less about the ways of the world than
might be expected given his/her intelligence or background.

Has an active and satisfying sex life.

Appears comfortable and at ease in social situations.

Tends to elicit dislike or animosity in others.

Tends to use his/her physical attractiveness to an excessive degree to gain
attention or notice.

Tends to fear s/he will be rejected or abandoned.

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Appears to associate sex with danger (e.g., injury, punishment, contamination),
whether consciously or unconsciously.

Tends to think in abstract and intellectualized terms, even in matters of personal
import.

Generally ﬁnds contentment and happiness in life’s activities.

Has a deep sense of inner badness; sees self as damaged, evil, or rotten to the core
(whether consciously or unconsciously).

Tends to have extreme reactions to perceived slights or criticism (e.g., may react
with rage, humiliation, etc.).

Appears to have little need for human company or contact; is emotionally
detached or indifferent.

Is suspicious; tends to assume others will harm, deceive, conspire against, or
betray him/her.

Tends to express emotion appropriate in quality and intensity to the situation at
hand.

Tends to express qualities or mannerisms traditionally associated with own gender
to an exaggerated or stereotypical degree (i.e., a hyper-feminine woman; a hyper-
masculine, “macho” man).

Tends to restrict food intake to the point of being underweight and malnourished.
Tends to engage in self-mutilating behavior (e.g., self-cutting, self-burning, etc.).
Tends to become attached to, or romantically interested in, people who are
emotionally unavailable.

Has the capacity to recognize alternative viewpoints, even in matters that stir up
strong feelings.

Appears impervious to consequences; seems unable or unwilling to modify
behavior in response to threats or negative consequences.

Experiences little or no remorse for harm or injury caused to others.

Tends to be critical of others.

Is prone to violence (e.g., may break things or become physically assaultive).
Tends to see own unacceptable feelings or impulses in other people instead of in
him/herself.

Is unable to soothe or comfort him/herself without the help of another person (i.e.,
has difﬁculty regulating own emotions).

Has difﬁculty maintaining attention and focus on tasks; is easily distracted by
sights, sounds, unrelated thoughts, or other competing stimuli.

Tends to be inhibited or constricted; has difﬁculty allowing self to acknowledge
or express wishes and impulses.

Has moral and ethical, standards and strives to live up to them.

Is creative; is able to see things or approach problems in novel ways.

Attempts to avoid feeling helpless or depressed by becoming angry instead.
Tends to adhere rigidly to daily routines and become anxious or uncomfortable
when they are altered.

Tends to avoid social situations because of fear of embarrassment or humiliation.

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Appearance or manner seems odd or peculiar (e.g., grooming, hygiene, posture,
eye contact, speech rhythms, etc. seem somehow strange or “off”).

Appears to have a limited or constricted range of emotions.

Tends to feel misunderstood, mistreated, or victimized.

Fantasizes about ideal, perfect love.

Tends to be conﬂicted about authority (e. g., may feel s/he must submit, rebel
against, win over, defeat, etc.).

Reasoning processes or perceptual experiences seem odd and idiosyncratic (e. g.,
may make seemingly arbitrary inferences; may see hidden messages or special
meanings in ordinary events).

Appears conﬂicted about experiencing pleasurable emotions; tends to inhibit
excitement, joy, pride, etc.

Tends to have numerous sexual involvements; is promiscuous.

Tends to be dismissive, haughty, or arrogant.

Tends to act impulsively (e. g., acts without forethought or concern for
consequences).

Is hypochondriacal; has exaggerated fears of contracting medical illness (e.g.,
worries excessively about normal aches and pains).

Tends to believe in supematural, paranormal, or superstitious phenomena or to be
drawn to “alternative” belief systems (e.g., astrology, tarot, crystals, psychics,
auras).

Is confused, conﬂicted, or uncertain about his/her sexual orientation (e. g., may
struggle to keep homosexual feelings out of awareness, have an exaggerated fear
of homosexuality, etc.).

Tends to enter altered, dissociated states when distressed (e.g., the self or world
feels strange, unreal, or unfamiliar).

Tends to hold grudges; may dwell on insults or slights for long periods.

Sexual fantasies or activities are unusual, idiosyncratic, or rigidly scripted (e.g.,
dominance, submission, voyeurism, fetishes, etc.).

Is invested in seeing and portraying self as emotionally strong, untroubled, and
emotionally in control, despite clear evidence of underlying insecurity, anxiety, or
distress.

Tends to make repeated suicidal threats or gestures, either as a “cry for help” or as
an effort to manipulate others.

Tends to believe s/he can only be appreciated by, or should only associate with,
people who are high-status, superior, or otherwise “special.”

Tends to see self as logical and rational, uninﬂuenced by emotion; prefers to
operate as if emotions were irrelevant or inconsequential.

Thought processes or speech tend to be circumstantial, vague, rambling,
digressive, etc. (e.g., may be unclear whether s/he is being metaphorical or
whether thinking is confused or peculiar).

Tends to elicit boredom in others (e.g., may talk incessantly, without feeling, or
about inconsequential matters).

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Tends to abuse drugs or alcohol.

Has little psychological insight into own motives, behavior, etc.

Tends to feel like an outcast or outsider.

Tends to identify with admired others to an exaggerated degree, taking on their
attitudes, mannerisms, etc. (e. g., may be drawn into the “orbit” of a strong or
charismatic personality).

Appears to experience the past as a series of disjointed or disconnected events;
has difﬁculty giving a coherent account of his/her life story.

Tends to repress or “forget” distressing events, or distort memories of distressing
events beyond recognition.

Relationships tend to be unstable, chaotic, and rapidly changing.

Tends to draw others into scenarios, or “pull” them into roles, that feel alien or
unfamiliar (e.g., being uncharacteristically insensitive or cruel, feeling like the
only person in the world who can help, etc.).

Tends to describe experiences in generalities; is reluctant to provide details,
examples, or supporting narrative.

Has a disturbed or distorted body-image (e. g., may see self as unattractive,
grotesque, disgusting, etc.).

Tends to become irrational when strong emotions are stirred up; may show a
signiﬁcant decline from customary level of functioning.

Appears afraid of commitment to a long-term love relationship.

Tends to deny or disavow own need for nurturance, caring, comfort, etc. (e.g.,
may regard such needs as weakness, avoid depending on others or asking for help,
etc.)

Lacks close friendships and relationships.

Tends to deny, disavow, or squelch his/her own realistic hopes, dreams, or desires
to protect against anticipated disappointment (whether consciously or
unconsciously).

Expresses contradictory feelings or beliefs without being disturbed by the
inconsistency; has little need to reconcile or resolve contradictory ideas.
Appears to want to “punish” self; creates situations that lead to unhappiness, or
actively avoids opportunities for pleasure and gratiﬁcation.

Tends to be self-righteous or moralistic.

Tends to distort unacceptable wishes or feelings by transforming them into their
opposite (e.g., may express excessive concern while showing signs of
unacknowledged hostility, disgust about sexual matters while showing signs of
unacknowledged excitement, etc.).

Tends to alternate between undercontrol and overcontrol of needs and impulses
(e.g., sometimes acts on desires impulsively while at other times denying them
entirely).

Is simultaneously needy of, and rejecting toward, others (e.g., craves intimacy and
caring, but tends to reject it when offered).

Struggles with genuine wishes to kill him/herself.

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Is afraid or conﬂicted about becoming like a parent (or parent ﬁgure) about whom
s/he has strong negative feelings (e.g., may go to lengths to avoid or reject
attitudes or behaviors associated with that person).

Tends to be oppositional, contrary, or quick to disagree.

Appears to fear being alone; may go to great lengths to avoid being alone.
Seems unable to settle into, or sustain commitment to, identity-deﬁning life roles
(e.g., career, occupation, lifestyle, etc.).

Tends to become absorbed in details, oﬁen to the point that s/he misses what is
signiﬁcant.

Expects self to be “perfect” (e. g., in appearance, achievements, performance,
etc.).

Tends to be conscientious and responsible.

Tends to confuse own thoughts, feelings, or personality traits with those of others
(e.g., may use the same words to describe him/herself and another person, believe
the two share identical thoughts and feelings, etc.).

Repeatedly convinces others of his/her commitment to change but then reverts to
previous maladaptive behavior; tends to convince others that “this time is really
different.”

Has a pervasive sense that someone or something necessary for happiness has
been lost forever, whether consciously or unconsciously (e. g., a relationship,
youth, beauty, success).

Tends to be energetic and outgoing.

Has trouble making decisions; tends to be indecisive or to vacillate when faced
with choices.

Tends to choose sexual or romantic partners who seem inappropriate in terms of
age, status (e.g., social, economic, intellectual), etc.

Tends to be controlling.

Is psychologically insightful; is able to understand self and others in subtle and
sophisticated ways.

Verbal statements seem incongruous with accompanying affect, or incongruous
with accompanying non-verbal messages.

Is prone to intense anger, out of proportion to the situation at hand (e. g., has rage
episodes).

Has difﬁculty directing both tender feelings and sexual feelings toward the same
person (e.g., sees others as nurttuing and virtuous or sexy and exciting, but not
both).

Tends to feel guilty or ashamed about his/her sexual interests or activities
(whether consciously or unconsciously).

Work-life and/or living arrangements tend to be chaotic or unstable (e.g., job or
housing situation seems always temporary, transitional, or ill-deﬁned).

Tends to feel unhappy, depressed, or despondent.

Appears to feel privileged and entitled; expects preferential treatment.

Emotions tend to change rapidly and unpredictably.

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Tends to be overly concerned with rules, procedures, order, organization,
schedules, etc. .

Lacks social skills; tends to be socially awkward or inappropriate.

Tends to be manipulative.

Tends to be preoccupied with death and dying.

Finds meaning and satisfaction in the pursuit of long-term goals and ambitions.
Tends to seek out or create interpersonal relationships in which s/he is in the role
of caring for, rescuing, or protecting the other.

Has trouble acknowledging or expressing anger toward others, and instead
becomes depressed, self-critical, self-punitive, etc. (i.e., turns anger against self).
Tends to be passive and unassertive.

Tends to ruminate; may dwell on problems, replay conversations in his/her mind,
become preoccupied with thoughts about what could have been, etc.

156

AXIS II CHECKLIST

Please circle NO or YES to indicate whether the statement describes your patient’s
enduring personality functioning. If you are unsure whether an item is really true of the
patient (or true enough to rate as present), circle NO.

1.

2.

11.
12.
13.

14.
15.

16.

17.

18.

19.

20.

21.

22.

A pattern of unstable and intense interpersonal relationships characterized by
alternating between extremes of idealization and devaluation

Adopts a miserly spending style toward both self an others; money is viewed as
something to be hoarded for future catastrophes

Affective instability due to a marked reactivity of mood (e. g., intense episodic
dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more
than a few days)

Almost always chooses solitary activities

Appears indifferent to the praise or criticism of others

Avoids occupational activities that involve signiﬁcant interpersonal contact,
because of fears of criticism, disapproval, or rejection

Behavior or appearance that is odd, eccentric, or peculiar

Believes that he or she is “special” and unique and can only be understood by, or
should associate with, other special or high-status people (or institutions)

Chronic feelings of emptiness

Consistent irresponsibility, as indicated by repeated failure to sustain consistent
work behavior or honor ﬁnancial obligations

Considers relationships to be more intimate than they actually are

Consistently uses physical appearance to draw attention to self

Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for
personal proﬁt or pleasure

Displays rapidly shifting and shallow expression of emotions

Excessive social anxiety that does not diminish with familiarity and tends to be
associated with paranoid fears rather that negative judgments about self

Failure to conform to social norms with respect to lawful behaviors as indicated
by repeatedly performing acts that are grounds for arrest

Feels uncomfortable or helpless when alone because of exaggerated fears of
being unable to care for himself or herself

Frantic efforts to avoid real or imagined abandonment (do not diagnose for self-
mutilating or suicidal behavior) '

Goes to excessive lengths to obtain nurturance and support from others, to the
point of volunteering to do things that are unpleasant

Has a grandiose sense of self-importance (e. g., exaggerates achievements and
talents, expects to be recognized as superior without commensurate
achievements)

Has a sense of entitlement, i.e., unreasonable expectations of especially favorable
treatment or automatic compliance with his or her expectations

Has a style of speech that is excessively impressionistic and lacking in detail

157

23.

24.

25.

26.

27.
28.

29.
30.
31.
32.
33.

34.
35.

36.
37.

38.
39.

40.

41.

42.

43.
44.

45.

46.
47.

48.

Has difﬁculty expressing disagreement with others because of fear of loss of
support or approval (do not diagnose for realistic fears of retribution)

Has difﬁculty initiating projects or doing things on his or her own (because of a
lack of self-conﬁdence in judgment or abilities rather than a lack of motivation or
energy)

Has difﬁculty making everyday decisions without an excessive amount of advice
and reassurance from others

Has recurrent suspicions, without justiﬁcation, regarding ﬁdelity of spouse or
sexual part

Ideas of reference (excluding delusions of reference)

Identity disturbance: markedly and persistently unstable self-image or sense of
self

Impulsivity in at least two areas that are potentially self-damaging (e. g.,
spending, sex, substance abuse, reckless driving, binge eating; do not diagnose
for suicidal or self-mutilating behavior)

Impulsivity or failure to plan ahead

Inappropriate or constricted affect

Inappropriate, intense anger or difﬁculty controlling anger (e.g., frequent displays
of temper, constant anger, recurrent physical ﬁghts)

Interaction with others is often characterized by inappropriate sexually seductive
or provocative behavior

Irritability and aggressiveness, as indicated by repeated physical ﬁghts or assaults

Is excessively devoted to work and productivity to the exclusion of leisure
activities and friendships (not accounted for by obvious economic necessity)

Is inhibited in new interpersonal situations because of feelings of inadequacy

Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her
own ends

Is often envious of others or believes that others are envious of him or her

Is overconscientious, scrupulous, and inﬂexible about matters of morality, ethics
or values (not accounted for by cultural or religious identiﬁcation)

Is preoccupied with details, rules, lists, order, organization, or schedules to the
extent that the major point of the activity is lost

Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or
ideal love

Is preoccupied with unjustiﬁed doubts about the loyalty or trustworthiness of
ﬁiends or associates

Is preoccupied with being criticized or rejected in social situations

Is reluctant to conﬁde in others because of unwarranted fear that the information
will be used maliciously against him or her

Is reluctant to delegate tasks or to work with others unless they submit to exactly
his or her way of doing things

Is suggestible, i.e., easily inﬂuenced by others or circrunstances

Is unable to discard worn-out or worthless objects even when they have no
sentimental value

ls uncomfortable is situations in which he or she is not the center of attention

158

49.

50.

51.
52.
53.

54.

55.

56.
57.
58.

59.

60.
61.
62.
63.
64.
65.
66.
67.

68.

69.
70.
71.

72.
73.
74.
75.
76.

77.
78.

Is unrealistically preoccupied with fears of being left to take care of himself or
herself

Is unusually reluctant to take personal risks or to engage in any new activities
because they may prove embarrassing

Is unwilling to get involved with people unless certain of being liked

Lack of close friends or conﬁdants, other than ﬁrst-degree relatives

Lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another

Perceives attacks on his or her character or reputation that are not apparent to
others and is quick to react angrily or to counterattack

Lacks empathy; is unwilling to recognize or identify with the feelings and needs
of others

Needs others to assume responsibility for most major areas of his or her life
Neither desires nor enjoys close relationships, including being part of a family
Odd beliefs or magical thinking that inﬂuences behavior and is inconsistent with
subcultural norms (e.g., superstitiousness, belief in clairvoyance, telepathy, or
“sixth sense”; in children and adolescents, bizarre fantasies or preoccupations)
Odd thinking and speech (e. g., vague, circumstantial, metaphorical,
overelaborate, or sterotyped)

Persistently bears grudges, i.e., is unforgiving of insults, injuries, or slights

Reads hidden demeaning or threatening meanings into benign remarks or events
Reckless disregard for the safety of self or others

Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
Requires excessive admiration

Shows arrogant, haughty behaviors or attitudes

Shows emotional coldness, detachment, or ﬂattened affectivity

Shows perfectionism that interferes with task completion (e.g., is unable to
complete a project because his or her own overly strict standards are not met)
Shows restraint within intimate relationships because of the fear of being shamed
or ridiculed

Shows rigidity and stubbornness

Shows self-dramatization, theatricality, and exaggerated expression of emotion
Suspects, without sufﬁcient bases, that others are exploiting, harming, or
deceiving him or her

Suspiciousness or paranoid ideation

Takes pleasure in few, if any, activities

Transient, stress-related paranoid ideation or severe dissociative symptoms
Unusual perceptual experiences, including bodily illusions

Urgently seeks another relationship as a source of care and support when a close
relationship ends

Views self as socially inept, personally unappealing, or inferior to others

Has little, if any, interest in having sexual experiences with another person

159

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