Does Depressive State Influence Reported Attachment Status?
To the Editor: The article by Levitan and colleagues1 contributes to the literatures on both attachment theory and atypical major depression. Indeed, the 2 constructs have natural affinities. Attachment is a psychological variable deservedly attracting increasing attention.2 Little, however, is known about the potential effect of depressive mood state on this interpersonal trait. To our knowledge, none of the extensive references that Levitan et al provide address this question. The difficulty in diagnosing Axis II personality disorders in the setting of an Axis I mood disorder is well known: both patients and clinicians may confuse current state with long-standing trait (see, eg, references 3-5). Is the same true for attachment status in the context of a mood disorder?
Levitan and colleagues evaluated subjects presenting with an episode of atypical depression. That such currently depressed individuals should report low scores on the Adult Attachment Scale for "a positive sense of self" and "sense of personal efficacy in dealing with life stress" and high scores on "fear of rejection" and "tendency to activate negative emotions when faced with an acute challenge" is hardly surprising. But does this reflect a true trait measurement, or state confounding trait? To answer this question would require reevaluating these subjects after their depressive symptoms remit with treatment. Perhaps the authors have already done so; if not, they should consider doing so. The true test of attachment status would be to demonstrate its stability in and out of depressive episodes.
1. Levitan RD, Atkinson L, Pedersen R, et al. A novel examination of atypical major depressive disorder based on attachment theory. J Clin Psychiatry. 2009;70(6):879-887. PubMed doi:10.4088/JCP.07m03306
2. Markowitz JC, Milrod B, Bleiberg KL, et al. Interpersonal factors in understanding and treating posttraumatic stress disorder. J Psychiatr Pract. 2009;15(2):133-140. PubMed doi:10.1097/01.pra.0000348366.34419.28
3. Hirschfeld RM, Klerman GL, Clayton PJ, et al. Assessing personality: effects of the depressive state on trait measurement. Am J Psychiatry. 1983;140(6):695-699. PubMed
4. Bronisch T, Klerman GL. Personality functioning: change and stability in relationship to symptoms and psychopathology. J Pers Disord. 1991;5:307-317.
5. Zanarini MC, Gunderson JG, Marino MF, et al. DSM-III disorders in the families of borderline patients. J Pers Disord. 1998;12:292-302.
Author affiliations: Department of Psychiatry, Weill Medical College of Cornell University; Department of Psychiatry, Columbia University College of Physicians & Surgeons; and New York State Psychiatric Institute, New York (Dr Markowitz) and the Department of Psychology, Long Island University, Brooklyn (Dr Meehan), New York. Financial disclosure: Dr Markowitz has received royalties from Basic Books, Oxford University Press, and American Psychiatric Press, Inc. Dr Meehan reports no financial or other relationship except the grant support described below. Funding/support: Funded in part by grants from the National Institute of Mental Health (MH079078, to Dr Markowitz) and the American Psychoanalytic Association Fund for Psychoanalytic Research (to Dr Meehan).
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