PERCEPTIONS OF PARENTING RECEIVED IN CHILDHOOD AND EARLY SEPARATION ANXIETY IN YOUNG MALES WITH ADJUSTMENT DISORDER INTRODUCTION
Συγγραφέας Ορέστης Γιωτάκος Γράφτηκε στις ,
The view that early socialization experiences in the family shape the structure and function of adult interpersonal relationships underlies psychoanalytic, object relations, and attachment theories. Bowlby (1980), theorized that the relationship between infant and parent affects the child’s ability to form affection bonds in later life. He concluded that “attachment behavior is held to characterize human beings from the cradle to the grave”. He also argued that the term “bonding” and “attachment” are similar but there are some important differences. Attachment is an instictive process, and bonding is perhaps best viewed as less clearly biologically determined. Main et al (1985), found that parents who were rated as secure in their own childhoods were reported to have secure attachments with their own infants. Several studies have been undertaken in the last decade examining evidence of such continuity and findings support the concept that dysfunctional parent-child attachment is likely to be a potent pathogenic variable (Parker et al, 1992).
The Parental Bonding Instrument (PBI) is a validated assessment tool to determine the quality of the family relationships, describing the perceptions an individual forms on his or her relationship with parents. With this useful for attachment research tool, the influence of early childhood bonding experiences with parents can classified in two dimensions: level of care or affection and level of control or protection – low versus high – (Parker et al, 1979). From these two dimensions, four classifications of parental bonding styles have been identified: optimal bonding, weak bonding, affectionate constraint, and affectionless control. The “affectionless control” style of bonding indicates high overprotective behavior with low care by the parent and has been characteristic of adults with depression (Goldney, 1985, Mackinon et al, 1993, Parker,1983), delinquency (Howard, 1981), and adolescent drug abuse (Clausen, 1996). The “affectionate constraint” (high care, high protection) appears to have some specificity to panic disorder (Parker & Gladstone, 1996). In contrast to less optimal bonding styles, optimal bonding (care plus support of independence) is typically associated with good perceived social support and positive psychosocial outcomes ( Ainsworth et al, 1978, Mark, 1994). Parker (1989), found a close relationship between all PBI scales for both monozygotic (MZ) and dizygotic (DZ) twins. The similarity of the MZ and DZ correlation suggested that little of the variation of the PBI scales could be attributed to genetic sources.
In 1993, Brown and Harris examined whether parental indifference and abuse have specificity to later anxiety or depression. In that study, both parental indifference and abuse (physical or sexual) raised the chance of both depression and anxiety in adult life. In addition, Thomson & Kaplan (1996) have provided an overview of childhood emotional abuse, and noted the need to develop instruments for its assessment. In 1997, Parker et al, described the development of the Measure of Parenting Style (MOPS), comprising refined PBI scales assessing parental indifference and over-control, as well as a scale assessing parental abuse. The authors found a correspondence between the relevant scales of the MOPS and PBI, and also that MOPS-abuse scale could remain integral to the MOPS or complement the standard PBI. They failed to establish higher parenting abuse score for the anxiety disorders but did, in relation to mothers only, link higher abuse scores with a clinical diagnosis of non-melancholic depression. This new scale was recently used, in parallel with the PBI, in patients with personality disorders (Parker et al, 1999).
Another main early socialization experience is the security of attachments or the separation anxiety. According to Bowlby’s early analysis (1973), anxiety about the security of attachments is a normal and adaptive evolutionary phenomenon, with pathological manifestations emerging only if the growing child is exposed to abnormalities in early bonding experiences. The “separation anxiety hypothesis of panic disorder” has received repeated endorsement by clinicians (Silove et al, 1996). Tentative indications emerged that persons with heightened separation anxiety were more liable to early onset of panic disorder with agoraphobia and a more disabling course of the adult disorder (Deltito et al, 1986, Laraia et al,1994). In 1993(a), Silove et al, reported the development of the Separation Anxiety Symptom Inventory (SASI), to record adults’ memories of such experiences over the first 18 years of life. It was found (Silove et al, 1993b) a linear trend for panic disorder patients to have higher SASI scores than generalized anxiety disorder patients. It was concluded that early separation anxiety may exerted a graduated risk, with moderate levels predisposing subjects to generalized anxiety and with higher levels increasing the risk for panic disorder. Silove et al, (1995a), found that patients with panic disorder with agoraphobia showed statistically elevated SASI scores, in contrast to the patients with simple phobia and generalized anxiety disorder who did not differed from subjects with no history of psychiatric illness. Furthermore, Lipsitz et al (1994), suggested that early separation anxiety may be a harbinger of severe and multiple anxiety disorders in adulthood, rather than a risk for panic disorder alone. It is possible that early separation anxiety is only one aspect of a nonspecific temperamental vulnerability to affective disorders in adulthood.
Many studies indicate that early socialization experiences, emotional responses to separations, the nature of the internal representations of attachment figures, and the maturity may play important roles in the development of adjustment disorder (Westenberg et al, 1999). Rosen and Martin (1996), examined the impact of a history of childhood abuse and neglect on soldiers’ adaptation to army life, using the Childhood Trauma Questionnaire. They found that emotional neglect during childhood may have a negative impact on soldiers’ ability to access social support within their units. In addition, it was found close relationship between adjustment dysfunction and parenting received in childhood in incarcerated young offenders (Biggam et al, 1998), and in high-school students who participated in an international exchange program (Fukurawa & Shibayama, 1994). Finally, it was found close relationship between adjustment dysfunction and early separation anxiety in adolescents who lived in campus during the summer (Thurber, 1999).
The purpose of this study was to investigate the links between the perception of parenting received in childhood and the levels of early separation anxiety in patients with adjustment disorder. Otherwise, to test the hypothesis that early socialization experiences is a pathogenetic variable in the development of adjustment disorder. To our knowledge, this the first study which investigate both the relationship between perceptions of parenting received in childhood and early separation anxiety in patients with adjustment disorder.
MATERIAL – METHOD
Fifty four men suffering from Adjustment Disorder, according to DSM-III-R, without co-morbidity with other psychiatric disorders, participated in this study. All patients were men, soldiers, during the initial period of military service. It is known that conscription entails many adaptation difficulties for the young soldiers. The sudden change of habituation in sleeping, feeding, and working, as well as, the inhibition of previous support system – family and friends -, compose the stressor that led to the diagnosis of adjustment disorder. Patients were referred because of symptoms of depression, anxiety, and impairment in occupational function. The sample included consecutive patients attending the Psychiatric Department of the General Army Hospital of Tripolis (Greece), during the first half of 2000, and were hospitalized for at least one day. All participants signed standard consent forms. Patients were administered the Structured Clinical Interview for the DSM-III-R, patients edition (SCID-P) , as well as the Structured Clinical Interview for the DSM-III-R Axis II Disorder (SCID-II) (Spitzer et al, 1990), and were diagnosed as having Adjustment Disorder without co-morbidity in Axis I and II. It should be noted that there are not significant differences between DSM-III-R and DSM-IV for the diagnosis of this disorder. According both DSM-III-R and DSM-IV (APA, 1994), Adjustment Disorder includes emotional or behavioral symptoms, as well as significant impairment in social or occupational functioning, in response to an identifiable stressor within three months of the onset of the stressor. As a control sample were used 78 soldiers, matched for age and education. Both patients and controls were Greeks, they had about the same social and cultural background, and they were living during the same period in the same campus, having generally the same living conditions. It should be noted that all participants had been found healthy during the initial period, because all recruits are screened for mental and somatic diseases and a large number of them with symptoms are excluded before any survey begins. Both patients and controls were administered the following questionnaires:
A questionnaire with the general demographic data.
2. The self-reported scale Symptom Checlist -90-Revised (SCL-90-R) (Derogatis, 1977), which consists of 90 items concerning psychological, behavioral, and somatic complaints during the last month. It includes nine subscales: somatization, obsession-compulsion, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychotism. The rating options were: (0=not existed, 1= light, 2=moderate, 3= heavy, 4=extremely heavy).
3. The self-report Measurement of the Parental Style (MOPS) (Parker et al, 1997), which consists of 15 items concerning the father and 15 items concerning the mother. It estimates the perception of parenting received in childhood, in their first 16 years of life. It creates three subscales for each of the parents : “indifference”, “overcontrol”, and “abuse”, with the rating option being “not true at all”, “slightly true”, “moderately true”, and extremely true”, generating scores of 1, 2, 3, and 4.
4. The Separation Anxiety Symptom Inventory (SASI) (Silove et al, 1996), a 15-item self-report measure developed to record adults’ memories of such experiences over the first 18 years of life. The rating options were: “not true at all”, “slightly true”, “moderately true”, “very true”, and “extremely true”, generating scores of 1, 2, 3, 4, and 5. Square root transformation of the SASI scores was made, according to the instructions of Silove et al (1996).
Statistical analysis were performed by the use of SPSS for MS Windows Release 8.0.0 (1997), and the procedure included Chi-square, independent samples t-tests, Pearson correlation analysis, and finally multiple regression analysis with forward and backward stepwise inclusion.
RESULTS
There were not found significant differences between patients and controllers in most of the demographic areas. Both samples had about the same age, educational, and cultural profile. Patients were significantly more frequently reported bad financial and bad parental relationships (Table 1). According to the predominant symptoms of adjustment disorder, 21 (38.8%) patients were classified as having the subtype of adjustment disorder with depressed mood, 6 (11.1%) with anxiety mood, 19 (35.1%) with mixed anxiety and depressed mood, 1 (1.8%) with disturbance of conduct, and 7 (12.9%) with mixed disturbance of emotions and conduct.
Table 2 shows that the SCL-90-R-total score, as well as all of the SCL-90-R-subscales scores, excluding psychotism, were significantly elevated in the patients’ group in relation to the control group (p
relation to the controls’ scores used for the standardization study of this scale in Greek population (Donias et al, 1991), which furthermore supports the healthy profile of the present controls. In addition, the patients’ SCL-90-R scores of the present study were significantly decreased in relation to the patients’ SCL-90-R scores used for the SCL-90-R standardization in Greek population, which contained different psychiatric diagnoses. This outcome furthermore supports the non-existence of co-morbidity of our patients’ sample.
The “father-MOPS-abuse” score, as well as the “mother-MOPS-abuse” score were significantly increased in the patients’ group (p Using the Pearson correlation method, it was found that the “MOPS-father-abuse” score has a significant correlation to the SCL-90-R-total score (p<0.01), as well as to the most of the SCL-90-R subscales (p<0.01). The “MOPS-mother-overcontrol” score showed significant correlation with the SCL-90-R-total, as well as with the SCL-90-R-subscales: obsessive-compulsive, depression, and paranoid ideation (p<0.01). The “MOPS-mother-overcontrol” subscale showed also significant correlation with the SASI score (p<0.01). Finally, SASI score showed significant correlation with the SCL-90-R-total score, as well as with its subscales anxiety and phobic anxiety (p<0.01), (Table 3).
Finally, multiple regression analysis showed that patients’ separation anxiety can be predicted from the levels of mothers’ overprotective behavior. It was also found that the severity of patients’ symptoms can be predicted from their fathers’ abusive behavior (p<0.05), (Table 4).
DISCUSSION
Focusing on the early socialization experiences, this study showed that, abusive and overprotective behavior of parenting received in childhood, as well as early separation anxiety, are important factors for the development of adult adjustment disorder. Certain limitations of the present study, including the small size of the sample, should be mentioned. All patients had the same stressor which led to the diagnosis of adjustment disorder. Furthermore, this study only included young males, whereas adaptation mechanisms and behavior differ in many ways between the sexes and the different age groups.
Conscription is a stressful psychosocial factor because of the sudden inhibition of all previous functions and the lack of previous support system, family and friends (Rosen & Martin, 1996, Nardi et al, 1994) . This stressful condition seems to share many similarities with separation anxiety conditions which underlies psychoanalytic and attachment theories. Concepts underlying the construct of separation anxiety have changed over time. Traditional psychodynamic theory regarded separation anxiety as an intrapsychic vulnerability (Frances & Dunn, 1975). Early attachment theory regarded separation anxiety as an emotional-behavioral pattern of children in such conditions (Bowlby, 1973). Recent studies on attachment theory suggest that “internal representations” of attachment figures, rather than the actual absence or presence of such figures, determines the individual’s attachment style and emotional response to separations (Sroufe, 1988). Many studies during the last decade have emphasized the existence of increased levels of early separation anxiety in patients with anxiety disorders, especially with panic disorder (Silove et al, 1995a, Manicavasagar V et al, 1998, Silove & Curtis, 2000). From the viewpoint of developmental psychopathology different models have been discussed. The most influential model proposes that early separation anxiety, when severe, may be transformed into panic disorder in adulthood (Shear et al, 1993). Other possibility is that early separation anxiety disorder persists into an adulthood form of the disorder, creating vulnerability to secondary disorders as panic disorder (Moreau et al, 1992). Finally, it is possible that early separation anxiety is only one aspect of a nonspecific temperamental vulnerability to affective disorders in adulthood (Silove et al, 1995 b). Patients with adjustment disorder of the present study showed significantly increased levels of early separation anxiety (SASI score) in comparison with controls (p<0.03, Table 2). It was found also that patients’ SASI score was significantly correlated with the total score of SCL-90-R, as well as with its subscales’ score of anxiety and phobic anxiety (Pearson correlation, p<0.01, Table 3). It can be suggested that early separation anxiety of adjustment disorder patients is highly correlated with the severity of the disorder and especially with the clinical manifestations of anxiety and phobia. Furthermore, multiple regression analysis showed that, patients’ separation anxiety can be predicted from the mother-overcontrol behavior (p<0.05, Table 4). It should be noted that reliability investigation of SASI showed that it generates scores that are not influenced by changes in state anxiety or depression (Silove et al, 1996), and that our reliability investigation showed a satisfactory internal consistency (Cronbach’s alpha, 0.90).
These clinical findings are in agreement with psychoendocrinological findings in animals. When separated from groups, suirrel monkeys respond with significant increases in plasma cortisol and adrenocorticotropic hormone (ACTH). While cortisol remains elevated above pre-separation levels, significant reductions occur in ACTH, which suggest that that reduction is mediated by corticosteroid feedback. Similar findings in humans have been reported in clinical studies of hypercortisolism and major depression (Lyons et al, 1999).
Several studies have suggested that dysfunctional parent-child attachment is likely to be a potent pathogenic variable (Parker et al, 1997). Favaretto and Torresani (1997), were analyzed the studies published between 1979 and 1995, which have used the PBI, and it was found that the perceived parental style, as measured by PBI, can be considered a good predictor for the presence of psychiatric disorder. It was found also that, with the exception of bipolar affective disorder and avoidant personality disorder, the prevalent parental style was for all diagnostic groups the affectionless control style. Similarly, results of the present study with adjustment disorder patients showed that parenting received style described as abusive and overprotective. Especially, patients’ scores of the father’s as well as mother’s MOPS-abuse subscale were significantly increased in comparison to controls (p< 0.001 and 0.000 respectively, Table 2). The score of father’s MOPS-abuse subscale was significantly correlated with the total score of SCL-90-R as well as with most of its subscales (Pearson correlation, p<0.01, Table 3), which suggests a significant correlation of father’s abusive behavior with the severity of symptoms. Furthermore, multiple regression analysis showed that the SCL-90-R score can be predicted from the father’s MOPS-abuse subscale score, which suggests that the severity of the disorder can be predicted from the father’s abusive behavior (p<0.05, Table 4). Using MOPS, Parker et al (1997), failed to establish higher parenting abuse score for the anxiety disorders but did, in relation to mothers only, link higher abuse score with a clinical diagnosis of non-melancholic depression.
The score of mother’s MOPS-overprotection subscale, in the present study, showed significant correlation with total score of SCL-90-R as well as its subscales obsessivity-compulsivity, depression, and paranoid ideation (p<0.01, Table 3), which suggests a significant correlation between maternal overprotection and severity of the symptoms. In addition, score of mother’s MOPS-overprotection subscale showed significant correlation with SASI score (p<0.01, Table 3). Multiple regression analysis showed that the patients’ levels of early separation anxiety can be predicted from the levels of maternal overprotection (p<0.05, Table 4). These findings are in agreement with Parker et al, 1997, who found that both panic disorder and social phobic patients reported higher maternal PBI protection scores, and higher parental MOPS over-control scores. Parental over-control have also been reported in patients suffering from panic disorder (Silove et al, 1991), and social phobia (Parker et al, 1983). Recently, Bennet and Stirling (1998), found relationship between trait anxiety and parental overprotection in a sample with anxiety disorders. Generally, the results of the present study are also in agreement with studies indicating that depressed people are more likely to report their parents as lacking care and being overprotective, as measured by the PBI (Parker et al, 1987).
Studies from Japan (Uehara et al, 1998) showed that child-rearing behaviors in non-Western cultures can be, similar to those in Western cultures. Furthermore, affectionless parental styles, as measured by the PBI, may be associated with depression in non-Western subjects, which suggests a stable and universal way of child-rearing behaviors. Although most studies of parenting have considered it to be an “environmental” variable, this perspective is likely to be an oversimplification. Several twin studies have suggested genetic influences on parenting (Hur and Buchard, 1995). Kendler (1996), especially, found that, genetic factors in both parent and child are more important for warmth than for protectiveness or authoritarianism. Parenting is a complex, dyadic process likely to be influenced by a range of factors, including, cultural beliefs of the parent about child rearing (Parker and Lipscompe, 1979), genetic temperamental characteristics of the parent (i.e., genetic factors influencing the provision of parenting) (Peruse et al, 1994), and genetic-temperamental characteristics of the child (i.e., genetic factors influencing the elicitation of parenting) (Bell, 1968). More clinical, epidemiological, and genetic research focusing in the mechanisms and processes that underlie the varied pathways from early socialization experiences to adult life could identify causal relationships and furthermore contribute to special therapies as well as to prevention of psychiatric disorders.
Table 1. General Demographic Data
Patients (n=54)
Controls (n=78)
Μean
S.D.
Μean
S.D.
p
Age
20,48
2,28
20,56
1,87
0,820
Days in the Army
34
17
30
0
0,048
Years of Education
11,7
2,52
12,51
3,03
0,109
Age of Father
50,52
8,56
50,62
5,96
0,938
Age of Mother
47,49
7,03
45,25
5,89
0,558
Siblings
1,56
0,96
1,76
1,37
0,354
n
%
n
%
Live in Urban area
37
68,52
58
76,32
0,323
Physical Parents
51
94,44
76
98,7
0,163
Low Financial
12
22,22
6
7,69
0,016*
Unmarried
54
100
75
96,15
0,144
Bad Relations between Parents
12
22,22
6
7,79
0,018*
Parents’ Separation or Divorce
11
20,75
10
12,99
0,237
Drug use (not addiction)
8
14,81
13
16,88
0,750
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