AN EMPIRICAL INVESTIGATION OF A NEW MEASURE TO ASSESS ADULT
ENTITLED DEPENDENCE PERSONALITY FEATURES
by
JAMES M. HICKS
B.A., University of Colorado Colorado Springs, 2013
A thesis submitted to the Graduate Faculty of the
University of Colorado Colorado Springs
in partial fulfillment of the
requirements for the degree of
Master of Arts
Department of Psychology
2017 ii
This thesis for the Master of Arts degree by
James M. Hicks
has been approved for the
Department of Psychology
by
Frederick L. Coolidge, Chair
Lori James
Daniel Segal
Date 05/03/2017 Hicks, James M. (M.A., Psychology)
An Empirical Investigation of a New Measure to Assess Adult Entitled Dependence
Personality Features
Thesis directed by Professor Frederick L. Coolidge
ABSTRACT
The present study explored the psychometric properties of a new measure of Adult
Entitled Dependence (AED). AED is defined as a condition characterized by the extreme
dependence of adult children on their parent(s), deemed deviant even when compared to
cultural norms, seemingly excessive in light of their apparent capacity to function
normally, and by high levels of dysfunction within the family (e.g., Lebowitz, Dolberger,
Nortov, & Omer, 2012). The AED scale was found to have excellent internal reliability and good test-retest reliability. A principle component analysis suggested the AED construct is comprised of 6 components: alexithymia, blaming/inadequacy, default dependence, aggression, somatization, and limited socialization. AED scale sums correlated positively and very strongly with passive-aggressive personality disorder, and positively and strongly with borderline, paranoid, narcissistic, obsessive-compulsive, sadistic, antisocial, schizotypal, and depressive personality disorder scale sums and showed a moderate positive relationship with the executive dysfunction of the frontal lobes as measured by the Coolidge Axis II Inventory (CATI). The results suggest that though personality disorders, executive dysfunction, and alexithymia clearly play a major role in AED, the word entitled may have been inappropriately attributed to these highly dependent adult children, as a weak relationship was found between AED and the grandiose, flamboyant, and attention-seeking (i.e., entitled) aspects of narcissism. iv
Keywords: Adult Entitled Dependence, highly dependent adult children, personality disorder, personality assessment, Coolidge Axis II Inventory, CATI v
DEDICATION
Dedicated to my parents: Patricia Sue, my North star, for always pointing me in the next right direction, and James Lee, for giving me the encouragement to continue the journey. vi
ACKNOWLEDGEMENTS
I am forever grateful to my mentors Frederick L. Coolidge, Thomas Wynn, Lori
James and Daniel Segal for their considerable time, infinite inspiration, unflinching encouragement, and gentle guidance. And to the students, staff, and faculty of the
University of Colorado, Colorado Springs for an unforgettable academic experience. TABLE OF CONTENTS
CHAPTER
I. INTRODUCTION ...... 1
A Brief History of Personality Theory and Personality Disorders ....3
Current DSM-5 Personality Disorders ...... 6
Previous Personality Disorders Heralding AED ...... 10
History of Highly Dependent Adult Children ...... 11
Adult Entitled Dependence in the Psychological Literature ...... 16
Contributions of Psychological Comorbidity to Adult Entitled Dependence ...... 22
Personality Theory Approach to Highly Dependent Adult Children...... 23
Hypothesis 1...... 24
Hypothesis 2...... 24
Hypothesis 3...... 24
Hypothesis 4...... 25
Hypothesis 5 (an exploratory hypothesis) ...... 26
Hypothesis 6 (an exploratory hypothesis) ...... 26
Hypothesis 7 (an exploratory hypothesis) ...... 26
II. METHOD ...... 27
Pilot Study Materials...... 27
Pilot Study Participants and Procedure ...... 28
Clinical Study Participants and Procedure ...... 29 viii
Clinical Study Materials ...... 31
III. RESULTS ...... 33
Hypothesis 1...... 33
Hypothesis 2...... 33
Hypothesis 3...... 33
Hypothesis 4...... 34
Hypothesis 5...... 35
Hypothesis 6...... 37
Hypothesis 7...... 38
IV. DISCUSSION ...... 39
Limitations and Future Studies ...... 50
Summary ...... 52
REFERENCES ...... 53
APPENDIX A: A Personality Study – Pilot Study Scale ...... 59
APPENDIX B: A Personality Pilot Study – Informed Consent ...... 62
APPENDIX C: Pilot Study – Demographic Information Form...... 65
APPENDIX D: Personality Study – Debriefing Statement ...... 66
APPENDIX E: A Personality Study – Clinical Study Scale ...... 67
APPENDIX F: New Personality Scale Clinical Study – Coolidge Axis Two Inventory (CATI), Male Significant Other Form ...... 70
APPENDIX G: New Personality Scale Clinical Study – Coolidge Axis Two Inventory (CATI) Female Significant Other Form ...... 84
APPENDIX H: Clinical Study – Demographic Information Form ...... 99
APPENDIX I: A Personality Study – Clinical Study Discriminant Validity Scale ..100
APPENDIX J: Exploratory Cluster Analyses ...... 103 ix
APPENDIX K: Exploratory Correlations Between AED Sum and Individual PD Scale Items on 9 Strongest Correlated PD Scales...... 105
APPENDIX L: Exploratory Analyses of AED Gender Differences ...... 115
APPENDIX M: UCCS Institutional Review Board Approval Letter ...... 119 x
LIST OF TABLES
TABLE
1. Correlations between AED Scale Sum and 14 CATI PD Scale Sums ...... 34
2. Summary of AED Scale Principal Component Analysis with Varimax Rotation ...... 35
3. Six Components of the AED Scale, Associated Items, and Factor Loadings ...... 36
4. Multiple Regression: Standardized Beta Coefficients, p Values, and Zero-Order Correlations...... 37
K1. Zero-Order Correlations between Individual Items on the CATI Passive-Aggressive Scale and AED Scale Sum...... 106
K2. Zero-Order Correlations between Individual Items on the CATI Borderline Scale and AED Scale Sum ...... 107
K3. Zero-Order Correlations between Individual Items on the CATI Paranoid Scale and AED Scale Sum ...... 108
K4. Zero-Order Correlations between Individual Items on the CATI Narcissistic Scale and AED Scale Sum ...... 109
K5. Zero-Order Correlations between Individual Items on the CATI Obsessive-Compulsive Scale and AED Scale Sum ...... 110
K6. Zero-Order Correlations between Individual Items on the CATI Sadistic Scale and AED Scale Sum ...... 111
K7. Zero-Order Correlations between Individual Items on the CATI Antisocial Scale and AED Scale Sum ...... 113
K8. Zero-Order Correlations between Individual Items on the CATI Schizotypal Scale and AED Scale Sum ...... 114
K9. Zero-Order Correlations between Individual Items on the CATI Depressive Scale and AED Scale Sum ...... 114 xi
L1. Total and Gendered Percentage of Subclinical and Clinical Psychopathology for AED, Executive Dysfunction of the Frontal Lobes, and 14 CATI PDs ...... 115
L2. Correlations between Female AED Scale Sum and 14 CATI PD Scale Sums ...... 116
L3. Correlations between Male AED Scale Sum and 14 CATI PD Scale Sums ...... 117 CHAPTER I
INTRODUCTION
To dream... To seek the unknown… To look for what is beautiful is its own
reward. A man’s reach should exceed his grasp, or what’s a heaven for?
—Nina Fawcett, The Lost City of Z, 2017
Beginning near the turn of the 21st century, the percentage of adult children domiciled with their parents around the world has steadily risen due to a constellation of global socioeconomic, technological, cultural, and psychological effects. At the outset of this discussion, two general subsets of these adult children will be distinguished. One group is behaving according to their cultural norms (e.g., living with one’s parents in a symbiotic relationship and sometimes later caring for them in their home). The other group is highly dependent upon their parents, to an extent that violates cultural norms.
The latter are known by different, generally derogatory colloquialisms around the world:
Bamboccioni in Italy (Janne, 2007), Boomerang Children in Canada (Settersten,
Furstenburg, & Rumbaut, 2005), Hikikomori in Japan (Teo, 2009), Kangurus in South
Korea, Mama’s Hotel Children in Austria (Lebowitz, Dolberger, Nortov, & Omer, 2012), and KIPPERS (Kids In Parents Pockets Eroding Retirement Savings) in England (Finlay,
Sheridan, McKay, & Nudzor, 2010). In the United States, this phenomenon has been dubbed “Full Nest Syndrome,” “Failure to Launch,” or “Returning Young Adult (RYA)
Syndrome.” The adult children are also referred to as “Incompletely Launched Young 2
Adults” or “Returning Young Adults.” Lebowitz and colleagues (2012) termed this
pathological behavior Adult Entitled Dependence (AED), defined as a chronic condition
involving a dysfunctional adult child and at least one parent who accommodates to the
pattern of dependence by providing age-inappropriate services to the highly dependent
adult child. This accommodation may appear to be excessive in light of the adult child’s
apparent capacity to function normally, that is, they do not exhibit any clear behavioral,
cognitive, or physical deficits that might otherwise impede their functioning. Highly dependent adult children may exhibit behaviors typical of AED including: termination of formal education, unemployment or employment avoidance, domicile within the parental home, demands for food, money, and other services, immersion in online computer activities, and inversion of the diurnal cycle (i.e., staying up at night, sleeping late into
the day). In extreme cases, some highly dependent adult children may react violently,
either toward their parents or toward themselves, when their demands are challenged or
not met. While the phenomenon of dependent adult children has been studied for the past
three decades, the majority of the work has been produced by economists, sociologists,
and family therapists. In the psychological and psychiatric literature, there is a lacuna of
information regarding AED. The present study aims to approach the phenomena of AED
from a personality disorder (PD) perspective. It is suggested that, along with other economic, sociocultural, and family systems influences, AED may be the sequelae of
PDs in highly dependent adult children. Further, AED may constitute a heretofore
unrecognized PD, that is, it “is an enduring pattern of inner experience and behavior that
deviates markedly from the expectations of the individual’s culture, is pervasive and
inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to 3 distress or impairment” (Diagnostic and Statistical Manual of Mental Disorders [DSM-
5]; American Psychiatric Association [APA], 2013).
A Brief History of Personality Theory and Personality Disorders
The study of personality can be traced to the ancient Greeks, whose early attempts at defining personality nearly 25 centuries ago centered on the doctrine of bodily humors, wherein one’s state of well-being could be attributed to the balance (or imbalance) of four bodily fluids, yellow bile, black bile, blood and phlegm (Millon, 2011; see also Segal,
Coolidge, & Rosowsky, 2006). The philosopher Hippocrates described the four basic temperaments: choleric, melancholic, sanguine and phlegmatic, corresponding to surplus amounts of yellow bile, black bile, blood and phlegm, respectively. Centuries earlier, the
Chinese based their philosophy of temperament on the concept of energy or chi. This chi was thought to be affected by climate, diet, and seasonal variations, resulting in changing human temperaments. In the 4th century B.C., Theophrastus, a student of Aristotle, began to record short descriptions of unique “characters,” literal portraits of common personality types stressing single, dominant traits, along with their flaws and foibles
(Rusten, 1993). In the mid-19th century, attempts at a pseudoscientific morphological explanation for temperament emerged in the form of phrenology, the theory espoused by
German neuroanatomist Franz Joseph Gall, which supposed that the intensity and character of thoughts and emotions correlated with variations on the morphology of the human body, specifically the cranium (Fodor, 1983). Late in the 19th and early 20th centuries, several theorists focused on character theory, with Ribot (1896) describing temperament in terms of sensitivity and activity; Heymans and Wiersma (1906-1909) suggesting activity level, emotionality, and external-versus-internal stimulation, and 4
Lazursky (1906) espousing a tripartite organization of character types, 1)
negative/detached/maladapted, 2) plastic/passive/dependent, and 3)
masterly/creative/independent. Modern formulations of personality theory emerged in the
early 20th century, concurrent with the work of German psychiatrist Kurt Schneider,
which centered on psychopathological personalities. According to Segal and colleagues
(2006), Schneider was the first to describe PDs not as precursors to more severe mental disorders, but as coexistent with other psychopathologies, and the first to propose that
PDs had roots in childhood and continued into adulthood. Schneider was also the first
psychologist to describe ten common clinical psychopathologies, thereby greatly influencing current psychopathological personality theory. His clinical psychopathologies included depressive personality (now known as depressive personality disorder), attention-seeking personality (histrionic personality disorder), labile personality
(borderline personality disorder), affectionless personality (antisocial personality disorder) and anankastic personality (obsessive-compulsive personality disorder). In the latter 20th century, the Five Factor Model, originally based on dimensions of typically normal personality traits (Costa & McCrea, 1992) and the Personality Psychopathology
Five (PSY-5; Harness, McNulty, & Ben-Porath, 1995), based on typical abnormal traits, dominated personality and PDs research.
An official diagnosis of PDs began with the publication of the first DSM (APA,
1952) that briefly described eight PDs (i.e., short paragraphs of a few sentences). In
DSM-II (APA, 1968), ten PDs were again described by a sentence or two of possible
symptoms. DSM-III (APA, 1980) isolated PDs to a separate axis from other clinical 5
syndromes, and specific criteria were noted for each disorder, as well as a minimum number of criteria (a polythetic approach) required to receive a clinical diagnosis.
Currently, there are two major systems for the diagnosis of PDs, the International
Classification of Diseases (ICD-10; World Health Organization, 2016) and the DSM-5
(APA, 2013), and each edition of these systems appears to have influenced the other. The former system defines PDs as severe disturbances in the personality and behavioral tendencies of the individual; not directly resulting from disease, damage, or other insult to the brain, or from another psychiatric disorder; usually involving several areas of the personality; nearly always associated with considerable personal distress and social disruption; and usually manifest since childhood or adolescence and continuing throughout adulthood.
The DSM-5 presents two approaches to modeling PDs: the extant categorical model described in Section II, and a new proposed hybrid categorical/dimensional model, described in Section III. The DSM-5 categorical model, originally introduced in DSM-III, divides PDs into three related groups: Cluster A (odd/eccentric) includes paranoid, schizoid, and schizotypal PDs; Cluster B (dramatic/emotional/erratic) includes antisocial, borderline, histrionic and narcissistic PDs; and Cluster C (anxious/fearful) includes avoidant, dependent, and obsessive-compulsive PDs, although full empirical substantiation of these clusters is lacking (e.g., Hyler & Lyons, 1988). The highly controversial hybrid personality disorder model introduced in Section III (Emerging
Measures and Models) described five broad domains (similar to the five-factor model of personality) for the PDs: negative affectivity, detachment, antagonism, disinhibition, and 6 psychoticism. Associated with these five domains were 25 maladaptive traits, claimed to be useful for their clinical relevance (e.g., Krueger, 2013).
Current DSM-5 Personality Disorders
The DSM-5 Section II currently includes 10 specific PDs, as follows:
Avoidant personality disorder, a pattern of social inhibition, feelings of
inadequacy, and hypersensitivity to negative evaluation. People suffering
from this disorder avoid employment that involves significant
interpersonal contact for fear of criticism, disapproval, or rejection. They
eschew new relationships because of feelings of inadequacy, and view
themselves as socially inept, unappealing, or inferior.
Narcissistic personality disorder, a pattern of grandiosity, need for
admiration, and lack of empathy. People suffering from this disorder
exaggerate their achievements and talents, expect to be recognized as
superior without commensurate achievements, and feel entitled to
favorable treatment and automatic compliance with their wishes.
Dependent personality disorder, a pattern of submissive and clinging
behavior related to an excessive need to be taken care of. People suffering
from this disorder have difficulty initiating projects (because of a lack of
self-confidence in judgment or abilities rather than a lack of motivation or
energy), need others to provide basic necessities, and have trouble making
everyday decisions without advice and reassurance from others.
Schizoid personality disorder, a pattern of detachment from social
relationships with a restricted range of emotional expression. People 7
suffering from this disorder are loners, show little pleasure (or other
emotions) or interest in forming intimate relationships, and prefer solitary
mechanical or abstract tasks, such as computer or mathematical games.
Paranoid personality disorder, a pattern of distrust and suspiciousness
such that the motives of others are interpreted as malevolent. People
suffering from this disorder assume that others intend to harm, exploit or
deceive them, without reason. They refuse to confide in others, perceive
hidden derogatory or threatening meanings in benign remarks or events.
They are unwilling to forgive, bear grudges, show jealousy, and react with
anger to perceived insults.
Schizotypal personality disorder, a pattern of acute discomfort in close
relationships, with concomitant cognitive or perceptual distortions and
eccentricities of behavior. People suffering from this disorder misattribute
causal inferences, exhibit magical thinking, suspiciousness, inappropriate
affect, and may behave in an odd or eccentric manner.
Antisocial personality disorder, a pattern of disregard for, and violation of,
the rights of others. People suffering from this disorder are deceitful and
manipulative, often violent, impulsive, irresponsible, and unremorseful.
They engage in criminal enterprises and exhibit a reckless disregard for
their own safety as well as the safety of others. They blame their victims
for their own disorderly behavior, claiming they are foolish, helpless, or
deserving of maltreatment. 8
Borderline personality disorder, a pattern of instability in interpersonal
relationships, self-image, and affect, with marked impulsivity. People
suffering from this disorder make frantic efforts to avoid real or imagined
abandonment, which result in intense, unstable relationships that alternate
between ideation and devaluation. They are impulsive and self-destructive,
and may exhibit sudden and extreme shifts in affect as well as their sense
of self. They may feel empty or even dissociative. Reacting to perceived
abandonment, they may threaten or attempt self-harm, including suicide.
Histrionic personality disorder, a pattern of excessive emotionality and
attention-seeking. People suffering from this disorder are uncomfortable if
they are not the center of attention. They can be inappropriately
promiscuous, using their physical appearance to attract attention. They can
be highly suggestible, fickle, and speak with an ambiguous,
impressionistic narrative. They are overly dramatic, embarrassing their
friends with public displays of excessive love, sadness, or anger.
Obsessive-compulsive personality disorder, a pattern of preoccupation
with orderliness, perfectionism, and control. People suffering from this
disorder maintain a sense of control via extreme pedantry in regard to
rules, procedures, lists, and schedules. Though they pay excessive
devotion to productivity to the exclusion of leisure time and other
relationships they become— so obsessed with perfection that projects are
seldom finished.— They are inflexible in moral or ethical judgments. They
tend to hoard material items long after they have become worn-out or 9
obsolete. Miserly, rigid, and stubborn, they may live far below the
standard they can afford.
Four other PDs were removed from DSM-IV (sadistic and self-defeating) or DSM-
5 (depressive and passive-aggressive). They are:
Sadistic personality disorder, a pervasive pattern of cruel, aggressive,
manipulative, and demeaning behavior directed toward others. People
exhibiting this disorder use physical violence to establish interpersonal
dominance, thereby restricting the autonomy of close relations. They are
amused by or enjoy the suffering of others, lacking empathy for their
suffering (DSM III-R; APA, 1987).
Self-defeating personality disorder, a pervasive pattern of self-defeating
behavior, beginning by early adulthood and present in a variety of
contexts. The person may often avoid or undermine pleasurable
experiences, be drawn to situations or relationships in which he or she will
suffer, and prevent others from helping him or her (DSM III-R; APA,
1987).
Depressive personality disorder, a pattern of cognitions and behaviors
including persistent and pervasive feeling of dejection, gloominess,
cheerlessness, joylessness, and unhappiness (DSM-IV; APA, 1994).
Passive-aggressive personality disorder, a pervasive pattern of
negativistic attitudes and passive resistance to demands for adequate
performance in social and occupational situations that begins by early
adulthood and occurs in a variety of contexts (DSM-IV; APA, 1994). 10
At this juncture, it may be important to raise the issue of what constitutes a
personality disorder. As noted by the definition of a personality disorder at the outset of
this discussion, a personality disorder is enduring, pervasive, and inflexible pattern of
inner experience and external behavior, deviating markedly from cultural norms, which
onsets early, remains stable, and is associated with distress or impairment (for one’s self
or others). In this DSM-5 definition, there is no mention of psychometric properties of a personality disorder scale such as: (1) internal reliability of criteria defining a personality disorder, (2) test-retest reliability of the measure, or (3) measures of validity like construct, discriminant, or concurrent validity. Further, there is no mention of disqualifying psychometric properties such as comorbidity with other syndromes or PDs or a lack of research interest in a particular personality disorder. The latter two conditions are important as the DSM-5 Personality Disorder Task Force had initially proposed to eliminate 5 of the current 10 PDs for either excessive comorbidity or lack of empirical research interest.
Previous Personality Disorders Heralding AED
In DSM (APA, 1952) and DSM-II (APA, 1968), two PDs were outlined that may have heralded some of the symptoms associated with the present concept of AED. In the first edition, the inadequate personality disorder was introduced as one of four cardinal personality types, described as rarely altered by any form of therapy. People suffering from inadequate personality disorder were characterized as having “inadequate response to intellectual, emotional, social, and physical demands. They are neither physically nor mentally grossly deficient on examination, but they do show inadaptability, ineptness, poor judgment, lack of physical and emotional stamina, and social incompatibility.” The 11
second edition offered a slightly altered definition of inadequate personality (disorder), along with a new asthenic personality (disorder), whose definitions are noted below.
Inadequate personality (disorder), characterized by inadequate response to
intellectual, emotional, social, and physical demands. They are neither
physically nor mentally grossly deficient on examination, but they do
show inadaptability, ineptness, poor judgment, lack of physical and
emotional stamina, and social incompatibility (DSM-II; APA, 1968).
Asthenic personality (disorder), characterized by easy fatigability, low
energy level, lack of enthusiasm, marked incapacity for enjoyment, and
oversensitivity to physical and emotional stress (DSM-II; APA, 1968).
Both PDs were eliminated from DSM-III (APA, 1980) without comment. These two prototypical PDs include the descriptions, “inadequate response to intellectual, emotional, social, and physical demands,” as well as “inadaptability, ineptness, poor judgment, lack of physical and emotional stamina, social incompatibility,” and,
“fatigability, low energy level, lack of enthusiasm, marked incapacity for enjoyment, and oversensitivity to physical and emotional stress,” the face validity of which appear highly similar to features of AED.
History of Highly Dependent Adult Children
Beginning in the mid-1980s, sociologists and economists took note of an emerging middle-class American family phenomenon commonly referred to as “crowded nest,” incompletely launched young adults (ILYAs), or returning young adults (RYAs), wherein young adults were returning to the family home after an unsuccessful attempt at autonomous independence. Settersten and Ray (2010) noted the dramatic increase 12
between 1970 and 2000 in the number of adult children domiciled with their parents in
the United States. Bell, Burtless, Gornick, and Smeeding (2007) have noted the decline in
the ability of young adults in six western countries (United States, Belgium, Canada,
Germany, Italy, and the United Kingdom) to form independent households between 1985 and 2000, based on an analysis of the Luxemburg Income Survey (LIS), a collection of comparable household income measures for a large number of nations. The LIS contains consistent time series information on individual-level earnings, by age, at several points in time for the six nations. Well into the 21st century, approximately 7 percent of adults aged 35 and approximately 5 percent of adults aged 40 lived with their parents, based on figures from the 2007 American Community Survey of the U.S. Bureau of the Census
(Settersten & Ray, 2010).
Like all sociocultural phenomena, the driving forces affecting ILYA or RYA are complex. Possible causal models encompass a multitude of variables from intrapersonal, to family systems, to changes in cultural, macro- and micro-economic, and geopolitical structures (White, 1994). Post-war fluctuations in life-course perspectives and expectations—due to cultural, economic, or geopolitical change—may have reshaped the
developmental landscape for young adults around the globe. This may be especially true
of the industrialized societies that enjoyed a post-war economic boom where achieving
economic independence in young adulthood was not only opportune, but became the
cultural norm during the 1950s (Mitchell, 2006). With the rise of the information
economy, education became highly valued and more young westerners achieved higher
academic goals than in previous generations. These educated young adults married early,
began lifelong careers, and started families. This post-war cultural ideal of the young, 13
upwardly mobile nuclear family was a paradigm shift from the multigenerational family
structures of the past in both industrialized and non-industrialized societies. This process
was reversed during the economic retreat of the late 1970s and 1980s. According to
Goldscheider, Goldscheider, St. Clair, and Hodges (1999), rising real estate costs and a
difficult job market encouraged young adults to remain at home as long as possible, to
both further their education and create enough wealth to be competitive in the housing
market. This may have produced the “mature co-residency” phenomenon (Mitchell,
Wister, & Gee, 2002), which has become the cultural norm in some modern
Mediterranean societies (Guiliano, 2007).
Goldscheider and Goldscheider (1998, 1999) suggest that, although leaving and
returning home may be a normative process in the United States in the late 20th century, in some cases, adult children fail to make the transition to full autonomy and return to the parental domicile, where they become chronically dependent upon parental support.
While many parent/adult child co-residencies around the globe may assume a benign form (i.e., both parents and adult children perceive co-residency as symbiotic) noted at the outset of this study, some early researchers suggested a malignant or pathological form of co-residency involving highly dependent adult children. In some of these latter
cases, open hostility may exist between the highly dependent adult child and other co-
resident parents or siblings (Lebowitz et al., 2012).
Two sociologists, Schnaiberg and Goldenberg (1989) offered four general
conditions that describe their “returning young adult syndrome,” a dysfunctional form of
co-residency involving highly dependent adult children: 14
1) The children’s failure to successfully reach functional autonomy, and the resultant economic dependency on the parent’s income.
2) Deviance from the parental expectations that children would physically separate from parents during “young adulthood.”
3) One or more returns to the parental home after having failed to reach functional autonomy.
4) An anomic context (i.e., outside the cultural norms) for household labor organization and allocation of family resources resulting in anger experienced by the parent(s) and/or child.
Without considering psychological influences, sociologists suggest several factors that precipitated the emergence of the ILYA or RYA syndrome, including post war changes in baby boomer parents’ child rearing ideology, where the emotional fulfillment of the child was emphasized for the first time, rather than education and financial independence, emphasized by preceding generations (Mitchell, 2006). Changes in adult development also occurred, emphasizing an increase in self-focused, expressive- individualistic behavior for older adults with the expectation that, once the rigors of childrearing were complete, older adults were now free to enjoy the fruits of their rewarding careers—which in many cases included both parents after the women’s liberation movement—without concomitant costs of supporting children in the family home. Perhaps the most important change during this period was the change in opportunity structure as western societies moved from an industrial economic base to information-based economies requiring a significant investment in post-secondary education. As global competition for these jobs increased, young adults may have had 15
fewer options regarding preferential schooling, more pressure to work during college, and
more familial indebtedness following the completion of higher education. With fewer
young adults able to afford higher education, competition for career entry level positions
may have increased, particularly in non-high tech fields. With decreased economic
opportunities, young adults may have begun waiting longer to marry and start families.
Many young adults, having experienced the dissolution of their parents’ marriage, may
have chosen to cohabitate with, rather than marry, their partners. The termination of these ad hoc, informal partnerships may have contributed to the return of many young adults.
However, it is important to note sociological studies of the ILYA or RYA syndrome often minimize or ignore psychological states and genetic predispositions and tend to focus on external rather than internal factors.
Other researchers approached the issue from an analytical perspective. South and
Lei (2015) analyzed data from the Panel Study of Income Dynamics Transition into
Adulthood survey that followed biannual waves of respondents from age 18 through 26 between 2005 and 2011. Using the timing of leaving and returning to the familial home, they found several factors predicted leaving, including forming romantic partnerships, entering higher education, entering the workplace after high school, and being physically or sexually abused. Family determinants included the education level of the mother (the higher the level of education attained by the mother, as well as the self-reported emotional distance from the mother, the more likely the young adult to move out).
Geographically, young adults in the North Central region where housing costs are lower
are more likely to move out than those in the higher cost North Eastern region. Several
factors predicted returning home, including: not attending college, remaining consistently 16
idle (unemployed and not seeking career training), the dissolution of a romantic partnership, a decline in parental health, not having a stepparent in the familial home or
the familial home already including adult children. While the ILYA/RYA syndrome
enjoyed modest economic and sociological investigation in the final decade of the 20th
century and beyond, these studies tended to minimize or ignore psychological states,
traits, or features of the individuals involved.
Adult Entitled Dependence in the Psychological Literature
In the postwar United States, psychosocial theory (Erikson, 1950) became the
dominant life course model in developmental psychology. It proposed a sequence of eight
stages of development, each stage presenting a crisis that must be resolved by the
individual. Young adulthood, lasting from late teens to about age 40, involved resolving
the crisis of intimacy-versus-isolation. Appropriate in mid-century industrialized
societies, when most people married, began stable long-term careers, and started families,
Erikson’s young adulthood stage no longer reflected the normative pattern of these same
industrial societies by the end of the 20th century (Arnett, 2016). Perhaps, with the
emergence of gender equality in the 1960s, birth control and the relaxing of sexual mores,
the transition to an information based economy and the concomitant need for higher
education, the median age of marriage had begun to rise. As young adults took additional
time to finish their extended education, travel, and volunteer, they often pursued menial
employment to help finance their tuition, travel, and volunteerism. Perhaps due to their
personal experience as children of divorce, many chose to cohabitate with romantic
partners as an alternative to marriage. In contrast to their parents, who had married and
started careers and families soon after high school, young adults of the late 20th century 17 took additional time before making enduring professional and romantic choices. In the late 1990s, developmental psychologists began to explore the advent of a new developmental paradigm, termed emerging adulthood (Arnett, 1998, 2000, 2007). Arnett
(2004) proposed five features that comprise the experience of emerging adulthood: identity explorations, self-focus, possibilities, instability, and feeling “in-between.” He noted that three cross-cultural criteria for reaching adulthood occurred during this period: accepting responsibility for oneself, making independent decisions, and becoming financially independent (Arnett, 2007). Emerging adulthood has been shown to be associated with a decrease in depressive symptoms and an increase in self-esteem
(Galambos, Barker, & Krahn, 2006; Schulenberg & Zarrett, 2006).
In 21st century industrialized nations, emerging adulthood appears to have extended the developmental process between adolescence and young adulthood.
Concomitant with this extension of the pre-adult developmental period, a paradigm shift in family systems may have occurred in many industrialized nations. Beginning near the turn of the 21st century, the percentage of adult children around the world residing with their parents increased steadily. It also appears true that many parents and adult children view their co-residency in a positive light. Many parents report satisfaction with co- resident adult children, with few reporting dissatisfaction (Aquilino & Supple, 1991;
Mitchell, 1998). As noted previously, in some industrialized cultures—especially southern European cultures—it is normative to remain co-resident until marriage, with both parents and adult children satisfied with co-residency (e.g., Giuliano, 2007;
Manacorda & Moretti, 2006). Co-residence with adult children may be a buffer against loneliness especially when parents are in the caregiving role (de Jong Gierveld, Dykstra, 18
& Schenk, 2012). Parents providing financial and emotional support to young adults have been shown to increase reciprocation in the future (Silverstein, Conroy, Wang, Giarrusso,
& Bengtson, 2002), and that emotional closeness, especially between the adult child and the mother, can predict co-residency (South & Lei, 2015). Co-residing with parents can offer adult children many advantages, including financial support, increased standard of living (e.g, use of goods and services provided by parents), as well as social and emotional support (Hartung & Sweeney, 1991; Mitchell, 2004).
In addition to the economic, family systems, and sociocultural factors that contribute to the benign form of co-residency, Lebowitz and colleagues (2012) provided some additional factors that may enable the transformation of the benign form into the maladaptive form of AED:
The ambiguous nature of the cultural expectations associated with
emerging adulthood leave modern families without a clear idea of when,
where, and how young adults should achieve financial independence
(Arnett, 2007).
The normative belief in western industrialized societies that every person
should search until they have found a career that is perfectly suited to their
talents and tastes (Collin & Young, 2000; Twenge, 2006).
The decrease in western parental authority (Omer, 2011).
The widespread availability of online media, communications, and
employment that enable physical isolation while creating the illusion of
social connection at a distance (Shaw & Black, 2008). 19
It is important to note, however, that AED heretofore has been approached from a
nomothetic perspective, as opposed to an idiographic one. This distinction is important
theoretically because the former perspective ignores individual characteristics and the
genetic bases for these characteristics. The additional factors that Lebowitz and
colleagues (2012) discussed with regard to enabling the transformation into a
maladaptive form of AED could be applied to any young adult, and all young adults should be equally susceptible to these general forces. Yet not all young adults are prone
to AED. The present study is an attempt to elucidate the idiographic characteristics of
AED.
As previously noted, Lebowitz et al. (2012) define AED as a chronic condition involving a dysfunctional adult child and at least one parent who accommodates to the pattern of dependence by providing age-inappropriate services to the highly dependent
adult child, excessive in light of the adult child’s apparent capacity to function normally.
The highly dependent adult child occupies the parental home, demands food, money, and
other services and refuses to attend school or seek employment. They may invert the
diurnal cycle (i.e., staying up at night, sleeping late into the day), only leaving their
bedroom when others in the household are away or asleep in order to meet their most
fundamental physiological needs (food, drink, and toilet), and immerse themselves in
online computer activities while awake. In extreme cases, some highly dependent adult
children may barricade themselves in their room, cut off all direct communication with family members and the outside world, and react violently, either toward their parents or
toward themselves when their demands are challenged or not met. However, there is
nothing in Lebowitz and colleagues’ causal speculations that suggests individual 20
differences or differing genetic predispositions that would make these highly dependent
adult children respond differently to the same cultural or socioeconomic conditions
experienced by their cohorts.
One previously noted pathological form of AED, which has been studied in
greater detail, is the Japanese phenomena of Hikikomori. Teo (2009) describes an epidemic—unknown prior to 1970, perhaps reaching hundreds of thousands of cases— wherein Japanese adolescents and young adults (4:1 preponderance of males) become recluses in their parents’ homes, withdrawing from friendships, contact with family, education, and employment. Average age at first presentation has been reported at 20- years-old in one small study and 27-years-old in a large government study (Kondo, 1997;
Ministry of Health, Labour & Welfare, 2003; Saito, 1998). Bullying, or other childhood trauma, has been reported in cases of Hikikomori, along with difficulty in school and shunning by peers. According to Kobayashi, Yoshida, Noguchi, Tsuchiya, and Ido
(2003), Hikikomori are known to barricade themselves in their rooms and exhibit violent outbursts, with 20% admitting to property destruction and assault upon family members.
Disrupted family dynamics have also been reported. Family members report that
Hikikomori tend to be rejecting and authoritative toward at least one family member, acknowledge a profound sense of apathy bordering on nihilism, and lack the motivation to engage with the world (Nabeta, 2003). They also have trouble describing their own identity (which may be a borderline personality disorder trait or a symptom of alexithymia). When asked to describe their feelings, thoughts, and interests, they respond with “I don’t know.” They may also express a desire to go against society, but feel an intense anxiety about doing so (Ogino, 2004). They may also experience intense feelings 21
of inadequacy. It appears that their isolating behavior varies: some never leave their room
or bathe, and relieve themselves in empty cans or containers. Others are willing to
emerge at times when they are unlikely to encounter others.
Although prevalent in Japan, this maladaptive form of highly dependent adult children, as noted earlier, can be found around the world. Sakamoto, Martin, Kumano,
Kuboki, and Al-Adawi (2005) report a case of Hikikomori involving a 24-year-old male
with extreme social withdrawal in Oman. In Spain, Malagón, Alvaro, Córcoles, Martín-
López, and Bulbena (2010), implementers of a psychiatric mobile unit in Barcelona, have
documented social isolation as the third most common consultation request among 475
cases documented across four years. They attribute the meager prevalence of these AED-
like cases to underdetection related to the isolation behavior itself as well as difficulties
families have with requesting help. Later, Malagón-Amor, Córcoles-Martínez, Martín-
López, and Pérez-Solà (2015) reported 164 cases of Hikikomori-like social withdrawal in
Barcelona, Spain (121 young men) with a mean age of 40 years. Cases involving AED or
Hikikomori-like social withdrawal have also been reported in Australia, Taiwan,
Bangladesh, Iran, India, Thailand, Korea, and the United States (Kato et al., 2012). To describe the fundamental behaviors seen in cases of AED, Lebowitz (2016) offers the following vignette:
Ivan was a 23-year-old man living at home with his parents since
attending a single semester of college at 18 years of age. Ivan had a
history of social and separation anxiety and was currently taking
fluoxetine 20 mg daily. He had twice begun therapy, only to stop after 2 to
3 sessions. Ivan had severed most social ties and spent most of his time in 22
his room, often sleeping during the day. Ivan’s parents provided lodging
and services, including laundry, utilities, and Internet access, gave him
money for expenses, and dealt with any necessary interactions with the
outside world. They refrained from inviting guests to the home because
this invariably distressed Ivan. His parents felt sorry for Ivan and
expressed the belief that he was unable to cope with life’s many
challenges. They also felt increasingly frustrated with his presence and
struggled to hide their disappointment from him. Attempts to deny Ivan
services or accommodations had backfired when he became angry and
distraught. On one occasion he had even become physically aggressive,
out-of-character behavior for which he later apologized. Ivan’s parents felt
trapped and believed that all their actions only made things worse. Ivan
also expressed his disappointment with life and occasionally made suicidal
statements. (p. 89)
Contributions of Psychological Comorbidity to Adult Entitled Dependence
According to Teo (2009), the Hikikomori have been diagnosed with withdrawal neurosis, social withdrawal, or social withdrawal syndrome. Notably, social anxiety and shyness are common complaints in Japanese culture, and avoidant personality disorder has been reported to be the most common personality disorder diagnosis. This could reflect a genetic predisposition, environmental factors or both, as well as diagnostic favoritism. Based on a hypothetical case vignette, Teo suggests possible diagnoses of avoidant personality disorder, schizoid personality disorder, anxiety disorder, social anxiety disorder, dysthymia, major depressive disorder or even schizophrenia. Koyama et 23
al. (2010) investigated the lifetime prevalence, psychiatric comorbidity, and
demographics of a community population in Japan, and found the local Hikikomori had
been diagnosed with the following DSM-IV clinical syndromes at some point in their
lives: psychiatric disorder, social phobia, specific phobia, alcohol abuse or dependence,
generalized anxiety disorder, hypomanic episode, major depressive disorder, dysthymic
disorder, and intermittent explosive disorder. Other diagnostic suggestions for cases of
AED include obsessive-compulsive disorder, depression, conduct disorder, attention
deficit hyperactivity disorder, learning disabilities, or dependent personality disorder
(Lebowitz et al., 2012).
Another possible comorbidity with AED is executive function deficits of the
frontal lobes (e.g., Luria, 1966; Hoffman, 2016). Patients with frontal lobe damage
frequently exhibit poor planning, difficulty making decisions (or exhibit an overreliance
on others to make decisions for them), task completion difficulties despite an ability to do
so, and problems with inhibition (impulsivity, lack of emotional control, risk-taking,
etc.). As frontal network dysfunction syndromes can result in some of the aforementioned
behavioral abnormalities seen in AED, a proportion of highly dependent adult children
may have undiagnosed executive function deficits.
Personality Theory Approach to Highly Dependent Adult Children
This study aims to approach the phenomenon of AED from an idiographic
personality theory perspective. It is possible that AED is an unrecognized personality disorder, because many of the AED traits in the literature were previously heralded by inadequate personality disorder and asthenic personality disorder in earlier editions of the
DSM. The purpose of the present study was to create a new AED scale from the 24
appropriate scholarly literature and evaluate it for internal reliability, test-retest
reliability, discriminant validity, and construct validity. The specific hypotheses are as
follows:
Hypothesis 1
Hypothesis 1 proposes the new AED scale will have good internal reliability
(Cronbach’s α > .80) and good to excellent test-retest reliability (i.e., r > .80 over a one- week interval).
Hypothesis 2
In a test of discriminant validity, Hypothesis 2 proposes the new AED scale sum will be significantly higher for those identified as having AED or AED features than those who are identified as not having AED or AED features (independent t test).
Hypothesis 3
Hypothesis 3A. The new AED scale will be positively and strongly correlated
with the avoidant personality disorder (i.e., r > .50).
Hypothesis 3B. The new AED scale would be positively and strongly correlated
with the dependent personality disorder (i.e., r > .50).
Hypothesis 3C. The new AED scale would be positively and strongly correlated
with the self-defeating personality disorder (i.e., r > .50).
Hypothesis 3D. The new AED scale would be positively and strongly correlated
with the passive-aggressive (negativistic) personality disorder (i.e., r > .50).
Hypothesis 3E. The new AED scale would be positively and moderately
correlated with the narcissistic personality disorder (i.e., r > .40). 25
Hypothesis 3F. The new AED scale would be positively and moderately
correlated with the schizotypal personality disorder (i.e., r > .40).
Hypothesis 3G. The new AED would be positively and moderately correlated
with the paranoid personality disorder (i.e., r > .40).
Hypothesis 3H. The new AED scale would be positively and moderately correlated with the antisocial personality disorder (i.e., r > .40)
Hypothesis 3I. The new AED scale would be positively and moderately correlated with the schizoid personality disorder (i.e., r > .40)
Hypothesis 3J. The new AED scale would be positively and moderately correlated with the depressive personality disorder (i.e., r > .40)
Hypothesis 3K. The new AED scale would be positively and moderately correlated with the borderline personality disorder (i.e., r > .40)
Hypothesis 3L. The new AED scale would be negatively and moderately correlated with the histrionic personality disorder (i.e., r < −.40).
Hypothesis 3M. The new AED scale would be negatively and weakly correlated with the obsessive-compulsive personality disorder (i.e., −.30 < r < −.10).
Hypothesis 3N. The new AED scale would be negatively and weakly correlated with the sadistic personality disorder (i.e., −.30 < r < −.10).
Hypothesis 4
Hypothesis 4 proposes that the new AED scale would be positively and moderately correlated with a measure of executive dysfunction of the frontal lobes (i.e., r
> .30).
26
Hypothesis 5 (an exploratory hypothesis)
Hypothesis 5 proposes the emergence of an underlying multifaceted construct for
the AED personality as measured by the AED scale based on a principal component analysis of the AED scale items.
Hypothesis 6 (an exploratory hypothesis)
Through multiple regression, Hypothesis 6 will explore the nature of the relationship of the AED scale to 14 personality disorder scales, as measured by the
Coolidge Axis II Inventory (CATI; Coolidge, 2013). The dependent variable will be the sum on the AED scale and the independent variables will be the sums on the CATI 14 PD scales.
Hypothesis 7 (an exploratory hypothesis)
Hypothesis 7 proposes that a cluster analysis will be able to identify subgroups of highly dependent adult children based upon their personality disorder traits (14 CATI PD scales) and the Executive Dysfunction scale. CHAPTER II
METHOD
The present study was divided into two phases: a pilot study focused on creating, norming, and validating a psychometric scale designed to measure AED symptomology, followed by a clinical study focused on using the AED scale to evaluate the general hypothesis that the maladaptive behaviors exhibited by highly dependent adult children may contribute to an emerging PD. The entire study was approved by the UCCS
Institutional Review Board.
Pilot Study Materials
AED Pilot Study Scale: a 32-item scale (see Appendix A) to assess the symptomology associated with highly dependent adult children and AED. To assess the symptomology, keyword Internet searches were conducted using Google, Google
Scholar, and the online subject database search engines provided by the Kraemer Family
Library, University of Colorado, Colorado Springs (UCCS) in order to retrieve the relevant literature. Search terms included failure to launch, returning young adults, full nest syndrome, incompletely launched young adults, hikikomori, boomerang children, kangurus, KIPPERS, adult entitled dependence, and highly dependent adult children. The relevant peer-reviewed literature was examined from which 32 aspects of AED symptomology were identified and used to create the scale items. Each item on the AED scale was rated on a Likert-type scale from 1 to 4 (1 = Hardly ever, 2 = Sometimes, 3 =
Frequently, 4 = Almost always). 28
Pilot Study Participants and Procedure
UCCS undergraduate psychology majors were recruited to participate in the pilot
study via the UCCS SONA system, and they received extra credit in their psychology courses for participating. Additionally, participants from the public were recruited via social media (e.g., Facebook), flyers posted on UCCS campus bulletin boards, and word- of-mouth. All participants were directed to an online research platform Qualtrics
(Qualtrics, Provo, UT) where they first provided informed consent (see Appendix B), then completed the AED scale regarding an adult (required criteria: sibling, friend, family member, or close acquaintance, 22 years or older, who is not their parent, and not mentally or physically disabled), a demographics form (see Appendix C), and were presented a debriefing statement (see Appendix D). In order to norm the AED scale, these pilot study participants were not asked to identify a highly dependent adult child, but only
to complete the pilot study AED scale about any adult who fits the aforementioned
criteria. The initial pilot study sample included 726 cases. Seventy-one cases were
removed due to one or more non-responses on the 32-item AED scale.
The final pilot study sample who reported on an adult was N = 665, 484 women,
178 men, 3 gender unreported, with a mean age of 29.82 (SD = 15.87) and a range of 17
to 87 years. Participant ethnicity was 72.6% White, 8.3% Hispanic, 1.7% African
American, 3.0% Asian/Pacific Islander, 0.9% American Indian/Alaskan Native, and
13.4% Other, with 0.2% not reporting their ethnicity.
The sample of targets, who met the pilot study criteria, was N = 665, 356 women,
303 men, 6 gender unreported), with 58.3% of the targets aged 22 to 29 years, 11.9%
aged 30 to 35, 7.2% aged 36 to 40, 22.0% aged 41 years or older, and 0.6% of targets 29 without reported ages. Target ethnicity was 75.6% White, 8.9% Hispanic, 2.9% African
American, 2.9% Asian/Pacific Islander, 1.1% American Indian, 8.1% Other, and 0.6% did not report ethnicity. Regarding their relationship to the target, 3.3% of the participants described the target as an acquaintance, 33.4% as a friend, 40.5% as family, 17% as a partner, and 5.4% as other, with 0.5% of the participants not reporting their relationship to the study target.
Data were downloaded from the Qualtrics platform and imported into an analytical software package (SPSS Version 24.0), where a scale reliability analysis was completed as an evaluation of Hypothesis 1 (internal reliability) and a principle components analysis (PCA) was completed as an evaluation of the exploratory
Hypothesis 5.
Clinical Study Participants and Procedure
The clinical study was conducted with a sample of convenience of UCCS undergraduate psychology students, who were asked to identify a potentially highly dependent adult child, according to the following description: “Think of a working age adult (22 years or older) you know that has no physical or mental disability, but he or she is highly dependent on their parents: not enrolled in college or vocational training, possibly unemployed, and living with and supported by their parents for at least one year.” The researcher contacted professors/instructors to recruit these participants, and they received in-class extra credit for participating. Participants who claimed to know a highly dependent adult child who met the above criteria offered verbal informed consent, then completed the AED clinical study scale (Appendix E) and the Coolidge Axis II
Inventory (see description below). The order of administration of the AED clinical study 30
scale and CATI was randomized. The AED clinical study scale was re-administered one
week later for a measure of test-retest reliability along with the AED clinical study demographic form. The demographics form (Appendix H)—which ensured the target’s anonymity as it did not ask for the name of the highly dependent adult child—was completed regarding both the participant and the target. Further, upon the second testing, participants were asked to complete a third copy of the AED scale (Appendix I) about an adult who did not meet the previously stated criteria for a highly dependent adult child, in order to test the AED clinical study scale for discriminant validity. Participants were then verbally debriefed in the classroom.
For the clinical study, the sampled undergraduate psychology students (the participants, N = 104) included 84 women and 20 men with a mean age of 24.20 years
(SD = 7.75) and a range from 17 to 56 years. The participant sample was homogeneous, with 69.2% White, 7.7% Hispanic, 4.8% African American, 1.9% Asian/Pacific Islander,
1.0% American Indian/Alaskan Native and 15.4% Other. The mean length of time participants had known the study target was 174.68 months (SD = 108.64), with a range of 4 to 468 months.
The clinical study targets (N = 104) were 36 women and 68 men identified as highly dependent (a working-age adult that is 22 years or older, has no physical or mental disability, not enrolled in college or vocational training, probably unemployed, and living with and supported by their parents, for at least one year). The target sample was homogeneous, with 65.4% White, 14.4% Hispanic, 5.8% African American, 1.0%
Asian/Pacific Islander, 1.0% American Indian/Alaskan Native and 12.5% Other. Target mean age was 29.90 years (SD = 9.88) with a range from 21 to 68 years. Note that two 31 targets were reported to be 21 years of age by their respective participants, one year below the requirement set forth in the description of highly dependent adult child. As the lower age bound of 22 was an arbitrary figure arrived at by the principle investigators with no patent effect on the outcome (other than to maximize possible psychopathology, i.e., highly dependent behaviors), the decision was made to analyze these two cases as valid examples of highly dependent adult children based on the other criteria. Regarding the targets’ length of dependence, 8.7% had been highly dependent for 1 to 2 years,
33.7% percent for 2 to 5 years, and 57.7% had been highly dependent for over 5 years.
Participants reported that 7.7% of the study targets were acquaintances, 21.2% were friends, 60.6% were family, 5.8% were romantic partners, and 4.8% were other types of relationships.
Clinical Study Materials
AED Clinical Study Scale. The participants in the clinical study completed the 32- item AED scale twice, a week apart (for test-retest reliability). On both occasions, they completed the scale regarding the same highly dependent adult child.
Coolidge Axis II Inventory (CATI). Participants in the clinical study also completed the 250-item, significant-other form of the CATI (Appendix F: Male, or
Appendix G: Female; Coolidge, Burns, & Mooney, 1995) about the highly dependent adult child they had identified. The CATI scales of interest were: (1) 14 PDs (10 from
DSM-5, 2 from the appendix of DSM-IV-TR (depressive and passive-aggressive), and 2 from DSM-III-R (sadistic and self-defeating), and (2) 16-item Executive Dysfunction of the Frontal Lobes scale, which measures poor planning, decision-making difficulties, and task completion problems. The items on the CATI are also rated on a Likert-type scale 32
from 1 to 4 (1 = Strongly false, 2 = More false than true, 3 = More true than false, 4 =
Strongly true). According to Coolidge (2013), the 14 PD scales in the CATI have a mean
test–retest reliability of r = .90 (one-week interval) and a median internal scale reliability
(Cronbach’s α) of .76 (range: Dependent PD scale = .87; Obsessive-Compulsive PD scale
= .68). The CATI PD scales had a median concurrent validity with the PD scales of the
Millon Clinical Multiaxial Inventory (Millon, 1987) of r = .52 (Coolidge & Merwin,
1992). As noted by Coolidge (2013), the CATI was normed on 937 adults (Mage = 29.2 years, range 18–92 years; 359 males, 578 females). Data were transferred from the hardcopy forms into SPSS Version 24.0 by the principle investigator and a research assistant, where a series of statistical analyses were completed to evaluate the remaining hypotheses. CHAPTER III
RESULTS
Hypothesis 1
It was hypothesized that the AED scale would have good internal reliability
(Cronbach’s α > .80) and good to excellent test-retest reliability (i.e., r > .80 over a one-
week interval). The pilot study scale reliability analysis (N = 665) resulted in a
Cronbach’s α = .93, thus exceeding the hypothesized internal reliability. The clinical study AED scale test-retest reliability over a one-week interval (N = 104) was r = .84, p <
.001, also exceeding the hypothesized reliability.
Hypothesis 2
As a test of discriminant validity, Hypothesis 2 proposed that the new AED scale
sum would be significantly higher for those identified as having AED features than those
who are identified as not having AED features. An independent t test revealed that the mean AED sum score for the highly dependent adult children (M = 81.32, SD = 15.37) was significantly higher than the mean for independent adult children (M = 44.00, SD =
10.03; t(206) = 23.73, p < .001), with a large correlation coefficient of effect size, r =
.731. Thus, there was prelimnary evidence of the discrimnant validity of the AED scale,
as hypothesized.
Hypothesis 3
The results of Hypotheses 3(A-N) appear in Table 1. To assess whether AED might
be conceptualized as a PD in the highly dependent adult child, Pearson product-moment 34
correlations were conducted between the AED scale score and the 14 PD scale scores on the CATI on N = 104 cases. The AED scale correlated moderately or strongly with 13 of the 14 PD scales of the CATI. The median correlation for all 14 hypothesized PD correlations was r = .55 (range r = .28 to .68). Of the 14 individual sub-hypotheses contained within Hypothesis 3, two were fully supported, nine were partially supported, and three were not supported (see Table 1).
Table 1
Correlations between AED Scale Sum and 14 CATI PD Scale Sumsa
Personality Disorder M (SD) r Hypothesis/ Result Direction/ Strength AED 81.32 (15.37) 1 Passive-Aggressive 67.50 (7.74) .68* 3D/Positive/Strong Full Support Borderline 61.28 (11.63) .59* 3K/Positive/Moderate Partial Support Paranoid 54.82 (9.98) .58* 3G/Positive/Moderate Partial Support Narcissistic 73.31 (12.32) .57* 3E/Positive/Moderate Partial Support Obsessive-Compulsive 71.03 (8.52) .57* 3M/Negative/Weak Not Supported Sadistic 40.48(10.00) .56* 3N/Negative/Weak Not Supported Antisocial 113.63 (24.08) .55* 3H/Positive/Moderate Partial Support Schizotypal 50.35 (9.09) .55* 3E/Positive/Moderate Partial Support Depressive 17.02 (3.86) .50* 3J/Positive/Moderate Partial Support Self-Defeating 52.25 (5.32) .41* 3C/Positive/Strong Partial Support Avoidant 44.67 (9.61) .40* 3A/Positive/Strong Partial Support Schizoid 19.42 (9.09) .38* 3I/Positive/Moderate Full Support Dependent 69.41 (10.23) .33* 3B/Positive/Strong Partial Support Histrionic 79.42 (11.62) .28* 3L/Negative/Moderate Not Supported * p < .01 (two-tailed), aN=104
Hypothesis 4
The fourth hypothesis predicted that the AED scale would be positively and moderately correlated with a measure of executive dysfunction of the frontal lobes (i.e., r
> .30). Executive dysfunction of the frontal lobes was positively and moderately
correlated with AED, r = .34, p < .01, therefore Hypothesis 4 was fully supported. 35
Hypothesis 5
The fifth (exploratory) hypothesis predicted the emergence of an underlying
multifaceted AED construct as measured by the AED scale based on a principal
components analysis (PCA) of the 32 AED scale items. A review of the intercorrelation
matrix of the 32 items revealed moderate to strong correlations among the items,
confirming that the data set was appropriate for PCA. A PCA was conducted using
varimax rotation, which produced six components with an Eigenvalue greater than 1.00, with a total of 55.26% of the variance explained [note: a promax rotation produced the
same results]. Additional PCAs were conducted by forcing 2, 3, 4, and 5 component
solutions, however, the 6-component solution was deemed most interpretable, therefore
exploratory Hypothesis 5 was fully supported. The six components were named based on
their individual items loadings. They included alexithymia, blaming/inadequacy, default
dependency, aggression, somatization, and limited socialization. A summary of these
PCA results appears in Table 2. Analyses of the content of each component and factor
loadings of the items appear in Table 3.
Table 2
Summary of AED Scale Principal Component Analysis with Varimax Rotationa Construct Items Eigenvalue Component Cumulative α Variance Variance 1 Alexithymia 8 10.64 11.84% 11.84% .86 2 Blaming/Inadequacy 5 2.003 11.14% 22.98% .84 3 Default Dependency 7 1.584 10.49% 33.47% .79 4 Aggression 6 1.323 8.37% 41.84% .70 5 Somatization 3 1.093 7.16% 49.00% .60 6 Limited 3 1.041 6.26% 55.26% .65 Socialization aN = 665
36
Table 3
Six Components of the AED Scale, Associated Items, and Factor Loadings Component Items Factor Loadings Alexithymia This person seems unaware of his/her feelings. .66 This person is inflexible. .65 This person minimizes face-to-face contact with others. .62 This person is socially inept. .59 This person behaves rigidly. .59 This person exhibits little understanding of .56 himself/herself. This person isolates him/herself from others. .51 This person has trouble adapting to changes. .46 Blaming/Inadequacy This person blames others for his/her inadequacies. .72 This person reacts emotionally if his/her demands are .66 not met. This person claims to be a victim of circumstances .66 beyond his/her control. This person is insensitive to others. .56 This person exhibits poor judgement. .55 Default Dependency This person relies on parents to provide him/her money, .73 goods, or services. This person justifies living at home with his/her parents. .64 This person relies on his/her parents’ resources (home, .62 utilities, food, TV, internet, etc.) for more than one year without working or attending school. This person’s parents attempt to enforce his/her .58 independence. This person has trouble completing simple tasks. .46 This person needs continual reassurance. .44 This person reports being bullied. .44 Aggression This person threatens others (like parents or siblings) if .63 his/her demands are not met. This person threatens self-harm if his/her demands are .57 not met. This person only communicates with other people .56 through his/her parents. This person does not work even though they are .46 physically and mentally capable. This person refuses to talk to some members of the .45 household. This person is unable to respond to simple requests by .41 authority figures. Somatization This person worries about his/her health. .66 This person is easily tired. .66 37
Component Items Factor Loadings This person has a physical reaction to stress (headaches, .64 sweating, upset stomach, muscle pain). Limited This person sleeps during the day and remains awake .67 Socialization throughout the night. This person is overly occupied with his/her computer, .54 smartphone, gaming, or the internet. This person refuses to attend school even though they .46 are physically and mentally able to do so.
Hypothesis 6
For the sixth hypothesis, a standard linear multiple regression (SPSS enter method) was used to evaluate how the AED level (dependent variable) would be predicted by the CATI’s 14 PD scale scores (independent variables). This analysis indicated that the 14 PD scale scores significantly accounted for AED levels, F (14, 89) =
14.44, p < .0005; R = .83, R2 = .69, Adjusted R2 = .65, including positive, significant relationships with antisocial, passive-aggressive, obsessive-compulsive, and schizoid
PDs. Thus, Hypothesis 6 was fully supported (see Table 4).
Table 4
Multiple Regression: Standardized Beta Coefficients, p Values, and Zero-Order Correlations Personality Disorder β p r Antisocial .43 < .01 .55 Passive-aggressive .35 < .01 .68 Obsessive-compulsive .34 < .01 .57 Schizoid .31 < .05 .38 Sadistic −.30 .09 .56 Dependent .25 .13 .33 Histrionic .15 .27 .28 Borderline .13 .34 .59 Self-defeating −.13 .13 .41 Avoidant −.13 .35 .40 Paranoid .10 .34 .58 Narcissistic −.08 .56 .57 Schizotypal .05 .65 .55 Depressive −.05 .65 .50 Note: Significant p values for standard beta coefficients are bolded. 38
Hypothesis 7
Hypothesis 7 investigated whether cluster analyses could identify subgroups of highly dependent adult children based on the 14 CATI PD scales and the Executive
Dysfunction scale. Examination of various numbers of clusters appeared to reveal only that the groups were clustered primarily on the magnitude of a scale rather than upon the nature of the scale, and no conceptually meaningful clusters could be identified. Thus,
Hypothesis 7 was not supported.
Nevertheless, two additional cluster analyses were conducted upon demographic information (younger and older men and women), and these results appear in Appendix J, suggesting the highest AED symptomology (highest T scores on AED scale) was found in older women and that length of dependence was directly related to T scores on the
AED scale.
Additional analyses of the individual items of the 9 strongly correlated PD scales with AED scale sum appears in Appendix K, showing how each item on each PD subscale correlated with AED scale sums, in effect, illustrating which facets of each PD subscale were related to highly dependent adult children and which were not. Additional exploratory analyses of elevated psychopathology (T scores on the AED scale, the 14
CATI PD scales, and Executive Dysfunction scale) was performed on the entire sample, followed by analyses by gender (see Appendix L), revealing significant gender differences in CATI PD scale scores and a parallel relationship between T scores on the
AED scale, Passive-Aggressive PD scale, and Executive Dysfunction scale. CHAPTER IV
DISCUSSION
Although many studies have attempted to quantify the nomothetic properties of
AED, the present study was an initial attempt to examine the idiographic characteristics of highly dependent adult children. The initial phase of the project involved the design and evaluation of a psychometric measure of AED (the AED scale). As such, the first hypothesis was substantiated: the AED scale exhibited excellent internal consistency in the general public sample and good test-retest reliability in the clinical sample. The second hypothesis was tentatively supported through an independent t test showing that participants rated highly dependent adult children significantly higher on the AED scale than independent adults. Hypotheses 3A through 3N evaluated the relationship among
AED, 14 PDs from the DSM, and a measure of executive dysfunction. For the 14 hypotheses regarding the relationship between AED and the PDs, 11 were generally supported and three were not supported, providing preliminary evidence that AED may be a manifestation of many kinds of personality disorder features. In the latter regard, there was a constellation of pathological behaviors including avoidance, e.g., social isolation including extreme physical isolation within the parental home, as well as an inversion of the diurnal cycle; self-defeating behaviors, e.g., cessation of employment, academic enterprise, intimate relationships, and other pleasurable activities outside the family home; and dependent behaviors, e.g., difficulty making prosocial or advantageous decisions, expecting parents to provide all physical and emotional needs without any 40
concomitant effort on the part of the adult child. In general, if AED could be
conceptualized as a PD, we would expect to see moderate to strong correlations with other measures of personality psychopathlogy. Although it was hypothesized that strong relationships would be evident with the avoidant, self-defeating, and dependent PDs
(based on their face validity and the behaviors comprising AED), instead the strongest relationships appeared with passive-aggressive, borderline, paranoid, narcissistic, and obsessive-compulsive PDs, respectively. In this respect, AED appears to display the closest behavioral relationships to passive-aggressive PD with its symptoms of anger, hypersensitivity, and retribution. AED’s borderline features consisted of emotional dysregulation and violence. Its paranoid features included jealousy, wariness, and interpersonal coldness. Its narcissistic features appeared to be self-centeredness and a lack of empathy, and obsessive-compulsive features included dysthymia and intolerance.
The strength of the correlation of the CATI’s Passive-Aggressive PD scale—in the combined sample as well as in both gender samples—as well as its significance and strength in the multiple regression analysis may lend support for AED’s consideration as a unique personality disorder or as a possible subtype of passive-aggressive PD. As noted earlier, passive-aggressive PD has had a varied history since its introduction in DSM
(APA, 1952). Ironically, the term passive-aggressive was originally applied to the immature and obstructive behaviors of noncompliant soldiers in a military setting (e.g.,
U.S. War Department, 1945; Wetzler & Morey, 1999). Their behaviors were characterized as a neurotic reaction to routine military stress, manifested by helplessness, inadequate responses, passiveness, obstructionism, or aggressive outbursts. The DSM divided it into three subtypes: passive-dependent (helpless, indecisive, clinging), passive- 41
aggressive (displaying pouting, stubbornness, procrastination, inefficiency, and obstructionism), and aggressive (displaying irritability, temper tantrums, resentment, and destructive behavior in response to frustration), which were all hypothesized in the DSM to conceal an underlying dependence. In DSM-II (APA, 1968), passive-aggressive PD was assigned separate diagnostic criteria, but also given a hidden motivation, dynamic environmental antecedents (i.e., its appearance was situationally dependent). As PDs are thought to be chronic and pervasive maladaptive traits evident across a variety of social, emotional, and cognitive domains, its situational dependence called into question its diagnostic validity. This resulted in an unusual exclusion criterion: a diagnosis of passive-aggressive PD could not be made in the presence of other comorbid PDs, the only PD to have such an exclusion (e.g., Wetzler & Morey, 1999). These exclusion criteria appeared to have artificially lowered the frequency of the diagnosis during ensuing research (e.g., Mellsop, Varghese, Joshua, & Hicks, 1982). With DSM-III (APA,
1980), the construct was expanded to include unreasonable criticisms, unjustifiable
protestations, obstructionism, resentment of suggestions and an inflated sense of one’s
own productivity, while the previous exclusion criteria were removed. These revisions
resulted in a significant increase (as much as 50%; e.g., Morey, 1988) in its diagnostic
frequency. For DSM-IV (APA, 1992), a controversial decision was made to remove
passive-aggressive PD from the Axis II disorders, based on an evaluation made by Millon
(1993). This evaluation included purported deficiencies in clinical acceptance, breadth of
definitional scope, cross-situational consistency, inferred underlying motivation, and
differentiation from other PDs. Millon suggested a substantial revision of the diagnostic
criteria, including his suggestion that the passive-aggressive PD be renamed negativistic 42
PD. It was then relegated to an appendix as a provisional diagnosis in DSM-IV and was subsequently removed from DSM-5.
Since then, substantial arguments have been made suggesting the passive- aggressive PD construct (e.g., Sprock & Hunsucker, 1998; Wetzler & Morey, 1999) be reinstated as a valid, reliable, prevalent, and clinically useful PD. Prior to its removal, passive-aggressive PD was found in 10% (Loranger, et al., 1994) and 12% (Morey, 1988) of selected personality disordered patients, a higher rate of diagnosis than schizotypal, schizoid, and obsessive-compulsive PDs. In community samples, passive-aggressive PD was diagnosed in 18% (Maier, Lichtermann, Klinger, Huen, & Hallmayer, 1992) and
23% (Moldin, Rice, Erlenmeyer-Kimling, & Squires-Wheeler, 1994) of personality disordered individuals, more than most other PDs. Interestingly, Becker, Grilo, Edell, and
McGlashan (2000) found that adolescents diagnosed with borderline PD had significant levels of comorbidity with passive-aggressive and schizotypal PDs, reflecting a similar pattern shown in the present study. Additionally, Small, Small, Alig, and Moore (1970), using a 15-year longitudinal design, found that 100 patients diagnosed with passive- aggressive PD developed emotional disturbances in adolescence, followed by interpersonal strife, verbal aggressiveness, outbursts of rage, impulsivity, manipulative behavior, along with a multitude of somatic complaints, a constellation of symptoms typical of the hikikomori and others displaying AED behavior.
With such an apparent intimate relationship between AED and the passive- aggressive PD, it is possible that AED could be a subtype of passive-aggressive PD, or more intriguingly, it might represent a unique PD. At the least, the recognition of AED features worldwide should provoke a reexamination of the validity and reliability of the 43 passive-aggressive PD and additional research into highly dependent adult children.
While other nomothetic factors (family systems dysfunction, socioeconomic pressures, technology that provides a sense of social connection at a distance, etc.) could contribute to the recent global recognition of AED, most young adults are exposed to similar challenges and do not become highly dependent. Therefore, additional examinations of individual differences may elucidate the underlying personality factors that result in the behaviors associated with AED.
To evaluate the relationship between the AED scale and the different items on each of the strongly correlated CATI PD scales, a series of post hoc exploratory correlations (see Appendix K) between the AED scale scores and the individual items on the nine strongly correlated PD scales were performed. A closer examination of the individual Passive-Aggressive PD scale items shows a stronger relationship between the negative-affect (anger, resentment, persecution) and retribution (delay, obstruction, or inaction as a form of revenge) components and a weaker relationship with the employment/task-oriented items, as one might expect in someone suffering from AED who appears very angry and resentful, but makes no attempt to achieve autonomy through gainful employment. A detailed examination of the individual borderline scale items shows a stronger relationship between the emotional dysregulation and violence components of borderline PD and a weaker relationship with the more ambiguous
“display of emotion.” This absence of a relationship between the AED construct and the display-of-emotions items may be due to the ambiguity of the term “emotional” which could also include displays of warmth, joy, sadness, or tenderness, resulting in a weak correlation due to the range of possible interpretations. The individual paranoid scale 44
items show a stronger relationship between jealousy, wariness, and interpersonal coldness
components of paranoid PD and a weaker relationship with the withholding of tender affection and neuroticism. Again, this may be due to the ambiguity of the term
“emotional.” Correlations with the individual narcissistic scale items show a stronger relationship between the self-centeredness and lack of empathy components of narcissistic PD and a weaker relationship with grandiose, flamboyant, or attention- seeking aspects of narcissism. A review of the individual obsessive-compulsive scale items shows a strong relationship between dysthymic and intolerant components of obsessive-compulsive PD and a weaker relationship with the attention to detail, control, and perfectionism aspects of obsessive-compulsive PD. Based on the historical inclusion of inadequate and asthenic PD exhibiting similar face validity, as well as the current study’s significant relationships between AED symptomology and 8 of the 10 current
PDs as well as 4 former PDs, the maladaptive behaviors associated with the AED construct may qualify for consideration and possible inclusion in Section II Diagnostic
Criteria and Codes of DSM-5, either as a newly derived, unique PD or possibly as a reemergence of the former passive-aggressive, inadequate, or asthenic PDs.
The fourth hypothesis was fully supported as the AED scale was positively and moderately correlated with a measure of executive dysfunction. As previously noted, patients with frontal lobe damage frequently exhibit poor planning, difficulty making decisions, and completing tasks, despite an ability to do so. These symptoms of executive dysfunction would seem to embody many of the maladaptive behaviors of AED. Studies have confirmed that executive dysfunction is highly heritable, as well as comorbid, in targets with PDs (e.g., Coolidge, Thede, & Jang, 2001, 2004). The latter found strong 45 positive correlations between executive dysfunction and PDs, including passive- aggressive, borderline, dependent, histrionic, and depressive PDs. Interestingly, Sarazin,
Pillon, Giannakopoulos, Rancurel, Samson, and DuBois (1998) found that some subjects with damage to the prefrontal cortex associated with executive functions showed minimal deficits in laboratory settings, while exhibiting severe deficits in natural settings. They suggest that decision-making and planning in natural settings may include a social, and therefore affective, aspect that is absent from the laboratory evaluations of executive functions. This may provide additional support for the role of executive dysfunction in
PDs as well as AED. This deficit in affective social functioning may also herald the role of alexithymia (discussion to follow) in contributing to the interpersonal dysfunction associated with AED. Clearly, there seems to be a unique relationship between AED, executive dysfunction, and PDs which bears additional study.
With regard to the fifth hypothesis using PCA, the AED construct appeared to encompass six reliable and stable components including alexithymia, blaming/inadequacy, default dependency, aggression, somatization, and limited socialization. As alexithymia accounted for the greatest variance in the PCA, it is interesting to note that Teo (2009) reported hikikomori were frequently unable to respond to questions regarding how they felt: their typical answer was, “I don’t know.”
Alexithymic people are said to have great difficulty identifying and distinguishing between feelings and bodily sensations and difficulty communicating their feelings (e.g.,
Sifneos, 1972). Thus, it is interesting that AED may also have some conceptual overlap with other forms of psychopathology besides the PDs. 46
If highly dependent adult children are alexithymic, their inability to distinguish
between their own feelings and bodily sensations may seriously impede their ability to
understand emotions in other people. Further, they may have trouble comprehending and
predicting the attitudes and thoughts of others, thereby impeding their own ability to
behave in a prosocial manner. Highly dependent adult children may become
overwhelmed by their own inadequate interpretation and response to the dynamic and
evolving emotional landscape of interpersonal bonds—ties that form the socioeconomic
hierarchies necessary to autonomously procure, accumulate, and secure resources. This
inability to understand and act upon one’s own emotions and the emotions expressed by
others may be one of their core issues from which the concomitant maladaptive responses
emanate. Further research should be conducted with validated self-report measures
alexithymia in order to confirm the present findings. As the ability to understand the
thoughts, attitudes, and feelings of others is labeled Theory of Mind in the literature (e.g.,
Baron-Cohen, 2000), further research with highly dependent adult children in the latter area might also be productive.
The second PCA component appeared to encompass blaming/inadequacy. This second strong component of the AED scale does raise the issue of the label “entitled” used by Lebowitz and colleagues (2012). The term entitled does have the connotation of an active, conscious, willful behavior between an adult child and their parents. If the highly dependent behavior is a byproduct of a constellation of PD features, many of which are egosyntonic, then the term entitled may be inappropriate. Curiously, Lebowitz et al. did not explicitly state their definition of entitled, however, it may be assumed that they used the term because they thought highly dependent adult children felt they 47 deserved special privileges, such as remaining physically and financially dependent upon their caregivers. However, if their dependence was primarily a function of egosyntonic
PD traits, alexithymic traits, executive dysfunction, blaming/inadequacy, and a lack of
Theory of Mind, then the underlying logic of the term entitled may be strongly questioned. Clearly, additional research into this specific issue of the appropriateness of the term Adult Entitled Dependence is warranted.
The third component appeared to incorporate default dependency. As noted, a defining characteristic of AED appears to be an interpersonal inadequacy that requires overwhelmed highly dependent adult children to return to a default state of dependency upon the financial and physical resources of their parents. Considering the first principal component, alexithymia, without a coherent emotional landscape, highly dependent adult children may have difficulty functioning in a prosocial manner, which is essential to forming and maintaining the relationships necessary to autonomously acquire and maintain resources. Early researchers such as Ruesch (1948) observed impaired verbalization in psychosomatic patients and attributed it to a continuation of “infantile personality” into adult life. As highly dependent adult children rely on those closest to them to provide basic necessities, it places them in a socially and physically vulnerable position. This may help to explain the childhood bullying reported by many highly dependent adult children, though these reports of bullying were negligible in the present study (possibly due to the participants’ ignorance of the targets’ history of being bullied).
The fourth component appeared to feature aggression—either active or passive— towards their caregivers. To ensure access to necessities they cannot provide for themselves, highly dependent adult children may attempt to directly or indirectly threaten 48
their caretakers to ensure their most basic needs. Their inability to provide for their own
basic needs may result in these aggressive acts. Further, these aggressive acts may explain the difficulties highly dependent adult children have with their siblings and other family members. In addition, other family members may interpret their behaviors as part of a kind of narcissistic entitlement, when the underlying pathology is much deeper and profound and has little to do with the primary narcissistic symptoms of grandiosity, fantasies of power, uniqueness/specialness, requiring excessive admiration, or arrogance.
This misinterpretation of the underlying motivations of highly dependent adult children may extend to mental health providers (e.g., Leibowitz et al., 2012). Importantly, if narcissistic traits are not causal factors in AED, then the term entitled (e.g., Adult Entitled
Dependence) may be entirely inappropriate.
The fifth component appeared to feature somatization. The three items from the
AED scale describing health worries, lethargy, and physical symptoms under duress, may
again be traced to the primary symptoms of alexithymia. Highly dependent adult
children, unable to distinguish their emotions from bodily sensations, may experience the
psychological dissonance associated with stressful situations as chronic pain, nausea, or
other physiological disturbance.
The sixth component appears to feature limited socialization. The zero-order
correlations between the AED scale and avoidant and schizoid PDs were nearly identical
(r = .40, and r = .38), respectively. However, the results of the multiple regression
showed that schizoid PD was a significant predictor and avoidant PD was not. Although,
not seen in the zero-order correlations, if subsequent investigations with multiple
regression confirms this finding, then the highly dependent adult children are passively 49
avoiding social relationships and interactions, which is consistent with schizoid PD traits.
Further, it has been amply demonstrated that schizoid PD is a highly genetic trait (e.g.,
Coolidge et al., 2001, 2004) which onsets early in childhood/adolescence. Again, this
reinforces the hypothesis that the word entitled is inappropriate, and these adult children
are merely acting consonantly with their strong genetic predispositions to not only avoid
others but to be alone.
The sixth hypothesis was supported by linear multiple regression, which showed
that the CATI’s 14 PD scale scores did significantly predict AED level (see Table 4).
Though it only achieved the sixth strongest correlation (r = .55) with AED scale scores, the Antisocial PD scale showed the strongest standardized beta coefficient (.43).
However, as might be expected given its zero-order correlation (r = .68), the passive- aggressive scale was also a significant predictor (β = .35), along with obsessive- compulsive (r = .57, β = .34) and schizoid (r = .38, β = .31). The results should be interpreted with caution, because the pattern of standardized beta coefficients could not be predicted from the zero-order correlation coefficients, which might be due to the multicollinearity between the predictors. As noted by Nathans, Oswald, and Nimon
(2012) reliance on standardized beta coefficients may be standard practice, but in reality, may be highly suspect. Perhaps, future investigations with larger samples may provide additional clarity.
The seventh hypothesis was unsupported. When the PD, AED, and executive dysfunction scale scores were used as variables for the cluster analysis, it appeared that the clusters simply formed on the basis of the scales’ magnitudes as opposed to unique combinations of PD trait characteristics. Nevertheless, subsequent post hoc cluster 50 analyses were able to determine differences, however, they were only based on demographic data (see Appendix J).
Limitations and Future Studies
Although the present study offers a promising alternative conceptualization of
AED based on a possible confluence of alexithymia, PDs, executive dysfunction, and perhaps other nomothetic influences, this evidence must be regarded as preliminary for several reasons. First, the lack of an inadequate PD or asthenic PD scale limits the ability to directly test the relationship between these two constructs and AED features, in spite of the face validity of the inadequate and asthenic PDs, which appear highly similar to behavioral features of AED. Also, a measure of alexithymia should be included in future studies to provide additional support for the initial evidence of alexithymia revealed by the PCA.
Second, the high multicollinearity of the independent variables in the regression analyses may have impeded the understanding of AED from the perspective of PDs.
Third, the clinical study could have benefitted from a preponderance of first-degree relationships, especially reports generated by daily caregivers (i.e. parents, direct family members, significant others, or other long-term, intimate relationships) rather than the greater range of relationships allowed in the present study. Fourth, the present study could have benefited from self-reports completed by highly dependent adult children themselves. Fifth, and one of the more serious confounding variables, was the design of the present discriminant validity test. The same participants were told to rate two different targets: a highly dependent adult as well as an adult who did not meet the dependence criteria. Thus, the significant differences between these two groups on the 51
measures may have been biased, a priori discrimination. Further, (sixth) the hypothesis was tested via independent t test, which may have been a violation of the assumption of independence of the samples because the same participant reported on two different targets. Additional evidence of discriminant validity should be provided via alternative methods. Future studies may also wish to assess parents, siblings, and offspring of highly dependent adult children in order determine the pattern of AED in families. The study could also be expanded to twins in order to determine the heritability of AED. Finally, the AED component structure should also be corroborated by a confirmatory factor analysis.
It is interesting that previous studies of highly dependent adult children typically report an approximately 4-to-1 preponderance of men to women (e.g., Malagón-Amor et
al., 2014; Teo, 2009). In the present pilot study of the general population of adults 22
years or older, the ratio of those who met criterion for AED (T > 70) was approximately
1:1. In the clinical study, the ratio was 2:1, thus, in the present study there was a greater
preponderance of highly dependent women than expected. Although, this finding may be
simply due to quirks of the samples, it raises the question of whether the increased
prevalence of AED in American women is artifactual or genuine. Is it possible that
American women do have a greater preponderance of AED compared to women in other
countries? Economic gender bias appears to be a well-established phenomenon
worldwide and not unique to the USA. Clearly, this issue requires further investigation.
Additionally, post hoc analyses (Appendices J & L) exposed curious gender differences
in level, type, and pattern of psychopathology that should be explored in future studies.
52
Summary
In sum, though the results did not offer complete support to the original hypotheses regarding the specific relationships between AED and particular PDs as measured by the CATI, the strength of the relationship with former and existing PDs, especially passive-aggressive PD, provides multiple paths of support (descriptive, correlational, and predictive) for the general hypothesis that AED may constitute a personality disorder, with its concomitant enduring, pervasive, and inflexible pattern of inner experience and external behavior associated with distress or impairment. It remains an open question as to whether AED is a newly emergent PD, a modern reemergence of a former PD (or one of its subtypes), a primary variant of alexithymia, or some combination of these, perhaps exacerbated by other nomothetic factors. The present study supports the 32-item AED scale as a valid and reliable measure for the maladaptive behaviors associated with AED, and that these behaviors may be related to the sequelae of alexithymia and other psychopathology (PDs, executive dysfunction, etc.) associated with highly dependent adult children.
Based on the present findings, where PDs, executive dysfunction, and alexithymia clearly play a major role in AED, it appears that the word entitled may be an inappropriate attribution to these highly dependent adults—a misnomer that may adversely affect the understanding of the true nature of AED. Further, since clinical interventions have already been designed to address AED, their focus on the narcissistic or entitled behavior may be inapropos. In light of these findings, perhaps the present
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Mitchell, B. A. (1998). Too close for comfort? Parental assessments of "boomerang kid" living arrangements. Canadian Journal of Sociology, 23, 21–46. 57
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Mitchell, B. A., Wister, A. V., & Gee, E. M. (2002). There's no place like home: An analysis of young adults' mature coresidency in Canada. The International Journal of Aging and Human Development, 54, 57–84.
Moldin, S. O., Rice, J. P., Erlenmeyer-Kimling, L., & Squires-Wheeler, E. (1994). Latent structure of DSM-III—R Axis II psychopathology in a normal sample. Journal of Abnormal Psychology, 103, 259–266.
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World Health Organization. (2016). Disorders of adult personality and behavior. In International statistical classification of diseases and related health problems (10th ed.). APPENDIX A
A PERSONALITY STUDY – PILOT STUDY SCALE
Personality Study Scale
Instructions
Think of a working-age (22 years or older) adult you know who is not your parent and has no physical or mental disability.
How accurately does each statement represent this person described above?
Please rate each of the items on the following scale:
1. Hardly Ever 2. Sometimes 3. Frequently 4. Almost Always
- CIRCLE Your Answer -
1. This person exhibits poor judgment. 1 2 3 4
2. This person is easily tired. 1 2 3 4
3. This person has trouble adapting to 1 2 3 4 changes.
4. This person does not work even though 1 2 3 4 they are physically and mentally capable.
5. This person justifies living at home with 1 2 3 4 his/her parents.
6. This person has trouble completing simple 1 2 3 4 tasks.
7. This person relies on parents to provide 1 2 3 4 him/her money, goods, or services.
8. This person needs continual reassurance. 1 2 3 4
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9. This person reacts emotionally if his/her 1 2 3 4 demands are not met.
10. This person claims to be a victim of 1 2 3 4 circumstances outside his/her control.
11. This person blames others for his/her 1 2 3 4 inadequacies.
12. This person refuses to talk to some 1 2 3 4 members of the household.
13. This person only communicates with 1 2 3 4 other people through his/her parents.
14. This person isolates him/herself from 1 2 3 4 others.
15. This person threatens self-harm if his/her 1 2 3 4 demands are not met.
16. This person is unable to respond to 1 2 3 4 simple requests by authority figures.
17. This person is overly occupied with his/her computer, smartphone, gaming, or 1 2 3 4 the internet.
18. This person sleeps during the day and 1 2 3 4 remains awake throughout the night.
19. This person’s parents attempt to enforce 1 2 3 4 his/her independence.
20. This person is socially inept. 1 2 3 4
21. This person worries about his/her health. 1 2 3 4
22. This person relies on his/her parents’ resources (home, utilities, food, TV, internet, 1 2 3 4 etc.) for more than one year without working or attending school.
23. This person reports being bullied. 1 2 3 4 61
24. This person refuses to attend school even though they are physically and mentally able 1 2 3 4 to do so.
25. This person threatens others (like parents 1 2 3 4 or siblings) if his/her demands are not met.
26. This person is insensitive to others. 1 2 3 4
27. This person minimizes face-to-face 1 2 3 4 communication with others.
28. This person behaves rigidly. 1 2 3 4
29. This person seems unaware of his/her 1 2 3 4 feelings.
30. This person is inflexible. 1 2 3 4
31. This person exhibits little understanding 1 2 3 4 of himself/herself.
32. This person has a physical reaction to stress (headaches, sweating, upset stomach, 1 2 3 4 muscle pain).
APPENDIX B
A PERSONALITY PILOT STUDY – INFORMED CONSENT
University of Colorado Colorado Springs (UCCS) Consent to be a Research Subject
Title: An Empirical Investigation of a New Personality Measure
Principal Investigator: James M Hicks
Funding Source: NONE
Introduction You are being asked to be in a research study. This form is designed to tell you everything you need to think about before you decide to consent (agree) to be in the study or not to be in the study. It is entirely your choice. If you decide to take part, you can change your mind later on and withdraw from the research study. You can skip any questions that you do not wish to answer.
Before making your decision: Please carefully read this form or have it read to you. Please ask questions about anything that is not clear.
Feel free to take your time thinking about whether you would like to participate. By agreeing to be in the study you will not give up any legal rights. You may want to print a copy of the consent form for your records.
Study Overview This study investigates personality traits. The results of this study may help us understand the underlying psychological traits associated with a particular personality. The results of this study may lead to an article published in a peer-reviewed journal about personality.
Procedures You are being asked to be in this approximately 15-minute research study because you may know a highly dependent adult child (a family member, friend, acquaintance, co-worker or classmate) 22 years or older who has no physical or mental disability, but is highly dependent on their parents (or other provider) while they are not enrolled in college or vocational training, perhaps unemployed, and have been living with and supported by their parents (or other provider) for at least one year. As part of the study, you will be asked to provide Informed Consent, and then complete a 25-item 63
questionnaire regarding the characteristics of the highly dependent adult child (herein referred to as the Significant Other), and a demographic questionnaire about the Significant Other (gender, age, race/ethnicity, education, religiosity, etc.). After completing the study, you will be debriefed.
Other people in this study: Up to 250 other people will participate in this study.
Risks and Discomforts: There is a minimal risk of emotional and/or psychological discomfort associated with participation in this study given that you will be disclosing information about a highly dependent adult child, referred to here as a Significant Other. You will be asked if your Significant Other (a family member, friend, employer, co- worker, or classmate) exhibits traits that might fit the description of a highly dependent adult child. All data received from participants will be de-identified through the use of unique identification codes. All materials will be kept in a locked cabinet after the completion of the study in order to minimize the chance of a breach of confidentiality.
Benefits This study is designed for the researcher to learn more about psychological traits in the general population. Participants will not receive direct benefit. While the study is not designed to provide direct benefits to those participating, participants may however find the study enjoyable, as contributing to the expanding body of knowledge may be pleasurable to students of psychology and members of the public interested in topics involving the exploration of human behavior.
Compensation There is no compensation for your participation in this study.
Confidentiality By participating in this study, the data you provide are assigned an ID number that is not connected to you in any way in order to protect your privacy and maintain confidentiality. All materials will be kept in a locked cabinet after the completion of the study in order to minimize the chance of a breach of confidentiality.
Your confidentiality will be maintained to the degree permitted by the technology used. Specifically, no guarantees can be made regarding the interception of data sent via the Internet by any third parties.
Certain offices and people other than the researchers may have access to study records. Government agencies and UCCS employees overseeing proper study conduct may look at your study records. These offices include the UCCS Institutional Review Board, and the UCCS Office of Sponsored Programs and Research Integrity. UCCS will keep any research records confidential to the extent allowed by law. A study number rather than your name will be used on study records wherever possible. Study records may be subject to disclosure pursuant to a court order, subpoena, law or regulation.
Voluntary Participation and Withdrawal from the Study
Taking part in this study is voluntary. You have the right to leave a study at any time without penalty. You may refuse to answer any questions that you do not wish to answer. 64
If you withdraw from the study, you may request that your research information not be used by contacting the Principal Investigator listed above and below.
Contact Information Contact (PI’s info): [email protected] if you have any questions about this study or your part in it, or if you have questions, concerns or complaints about the research, or if you would like information about the survey results when they are prepared.
Contact the Research Integrity Specialist at 719-255-3903 or via email at [email protected]: if you have questions about your rights as a research participant, or if you have questions, concerns or complaints about the research.
Electronic Consent «ID» Please print a copy of this consent form for your records, if you so desire.
I have read and understand the above consent form, I certify that I am 18 years old or older and, by clicking the NEXT button to enter the survey, I indicate my willingness to voluntarily take part in the study. 65
APPENDIX C
PILOT STUDY – DEMOGRAPHIC INFORMATION FORM
About YOU About the SIGNIFICANT OTHER What is your gender? ______What is his/her gender? ______
What is your age? ______What is his/her age? ______
What is your ethnicity? (check all that What is his/her ethnicity? (check all that apply) apply) ___ White ___ White ___ Hispanic/Latino ___ Hispanic/Latino ___ African American/Black ___ African American/Black ___ Asian/Pacific Islander ___ Asian/Pacific Islander ___ American Indian/Alaska Native ___ American Indian/Alaska Native ___ Other ___ Other
How long have you known the Significant Other person? ______months
What is your relationship with the Significant Other? ___ Acquaintance ___Friend ___Family ___Romantic Partner ___Other: ______
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APPENDIX D
PERSONALITY STUDY – DEBRIEFING STATEMENT
An Empirical Investigation of the Adult Entitled Dependence Personality Disorder
Thank you for your participation in our study. The purpose of the study is to explore the reliability and validity of an emerging personality diagnosis, the Adult Entitled Dependence Personality Disorder, which may contribute to Adult Entitled Dependence, a condition characterized by the extreme dependence of grown children on their parents (or other providers), seemingly excessive in light of their apparent capacity to function, and by levels of dysfunction within the family system. Adult Entitled Dependence has been studied from a sociological perspective (cultural factors influencing Adult Entitled Dependence), from economic perspectives (why do some adult children fail to earn as much as their parents?), and from a family therapy perspective (how can we help families suffering from dysfunctional behaviors associated with Adult Entitled Dependence?). The present study will differ from previous research, as the focus will be exploring the psychological variables that might influence Adult Entitled Dependence.
There was no deception used in the conduct of this study. However, should you feel discomfort or distress for any reason upon completion of this study, please contact the University Counseling Center at (719) 255-3265 or by going to 324 Main Hall. If you should have any questions concerning your participation, please feel free to contact Professor Frederick L. Coolidge at (719) 255-4146, or [email protected]. The researcher will also be available for any additional information and may be contacted through email: James Hicks, [email protected].
Your participation during this study was important to advance our understanding of PDs, and is greatly appreciated. A report of this research should be ready for circulation by the end of April 2017. If you would like to receive a copy, please send an email to James Hicks or Professor Coolidge expressing your interest in the results after April 2017. ]
Thank you again for your participation! APPENDIX E
A PERSONALITY STUDY – CLINICAL STUDY SCALE
Personality Primary Study Scale
Instructions
Think of a working age adult (22 years or older) you know that has no physical or mental disability, but he or she is highly dependent on their parents: not enrolled in college or vocational training, possibly unemployed, and living with and supported by their parents for at least one year.
How accurately does each statement represent this person described above?
Please rate each of the items on the following scale:
1. Hardly Ever 2. Sometimes 3. Frequently 4. Almost Always - CIRCLE Your Answer - 1. This person exhibits poor judgment. 1 2 3 4
2. This person is easily tired. 1 2 3 4
3. This person has trouble adapting to 1 2 3 4 changes.
4. This person does not work even though 1 2 3 4 they are physically and mentally capable.
5. This person justifies living at home with 1 2 3 4 his/her parents.
6. This person has trouble completing simple 1 2 3 4 tasks.
7. This person relies on parents to provide 1 2 3 4 him/her money, goods, or services.
8. This person needs continual reassurance. 1 2 3 4
68
9. This person reacts emotionally if his/her 1 2 3 4 demands are not met.
10. This person claims to be a victim of 1 2 3 4 circumstances outside his/her control.
11. This person blames others for his/her 1 2 3 4 inadequacies.
12. This person refuses to talk to some 1 2 3 4 members of the household.
13. This person only communicates with 1 2 3 4 other people through his/her parents.
14. This person isolates him/herself from 1 2 3 4 others.
15. This person threatens self-harm if his/her 1 2 3 4 demands are not met.
16. This person is unable to respond to 1 2 3 4 simple requests by authority figures.
17. This person is overly occupied with 1 2 3 4 his/her computer, smartphone, gaming, or the internet.
18. This person sleeps during the day and 1 2 3 4 remains awake throughout the night.
19. This person’s parents attempt to enforce 1 2 3 4 his/her independence.
20. This person is socially inept. 1 2 3 4
21. This person worries about his/her health. 1 2 3 4
22. This person relies on his/her parents’ resources (home, utilities, food, TV, internet, 1 2 3 4 etc.) for more than one year without working or attending school.
23. This person reports being bullied. 1 2 3 4 69
24. This person refuses to attend school even 1 2 3 4 though they are physically and mentally able to do so.
25. This person threatens others (like parents 1 2 3 4 or siblings) if his/her demands are not met.
26. This person is insensitive to others. 1 2 3 4
27. This person minimizes face-to-face 1 2 3 4 communication with others.
28. This person behaves rigidly. 1 2 3 4
29. This person seems unaware of his/her 1 2 3 4 feelings.
30. This person is inflexible. 1 2 3 4
31. This person exhibits little understanding 1 2 3 4 of himself/herself.
32. This person has a physical reaction to stress (headaches, sweating, upset stomach, 1 2 3 4 muscle pain).
APPENDIX F
NEW PERSONALITY SCALE CLINICAL STUDY – COOLIDGE AXIS TWO
INVENTORY (CATI), MALE SIGNIFICANT OTHER FORM
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74
75
76
77
78
79
80
81
82
83
APPENDIX G
NEW PERSONALITY SCALE CLINICAL STUDY – COOLIDGE AXIS TWO
INVENTORY (CATI) FEMALE SIGNIFICANT OTHER FORM
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87
88
89
90
91
92
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94
95
96
97
98
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APPENDIX H
CLINICAL STUDY – DEMOGRAPHIC INFORMATION FORM
New Personality Scale Primary Clinical Study Demographic Information Form
About YOU About the HIGHLY DEPENDENT ADULT CHILD What is your gender? ______What is his/her gender? ______
What is your age? ______What is his/her age? ______
What is your ethnicity? (check all that What is his/her ethnicity? (check all that apply) apply) ___ White ___ White ___ Hispanic/Latino ___ Hispanic/Latino ___ African American/Black ___ African American/Black ___ Asian/Pacific Islander ___ Asian/Pacific Islander ___ American Indian/Alaska Native ___ American Indian/Alaska Native ___ Other ___ Other
How long have you known the Highly To your knowledge, how long has he/she Dependent Adult Child? ______months exhibited the highly dependent behavior?
____ over 1, less than 2 years ____ over 2, less than 5 years ____ over 5 years
What is your relationship with the Highly Dependent Adult Child? ___ Acquaintance ___Friend ___Family ___Romantic Partner ___Other: ______
APPENDIX I
A PERSONALITY STUDY – CLINICAL STUDY DISCRIMINANT VALIDITY
SCALE
Personality Scale Clinical Study – DISCRIMENANT VALIDITY
Instructions
Think of a working-age adult (22 years or older) you know that has no physical or mental disability, and he or she is NOT highly dependent on their parents: they are ENROLLED in college or vocational training, or employed, and have NOT been living with and supported by their parents for at least one year.
How accurately does each statement represent this person described above?
Please rate each of the items on the following scale:
1. Hardly Ever 2. Sometimes 3. Frequently 4. Almost Always -Circle Your Answer- 1. This person exhibits poor judgment. 1 2 3 4
2. This person is easily tired. 1 2 3 4
3. This person has trouble adapting to 1 2 3 4 changes.
4. This person does not work even though 1 2 3 4 they are physically and mentally capable.
5. This person justifies living at home with 1 2 3 4 his/her parents.
6. This person has trouble completing simple 1 2 3 4 tasks.
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7. This person relies on parents to provide 1 2 3 4 him/her money, goods, or services.
8. This person needs continual reassurance. 1 2 3 4
9. This person reacts emotionally if his/her 1 2 3 4 demands are not met.
10. This person claims to be a victim of 1 2 3 4 circumstances outside his/her control.
11. This person blames others for his/her 1 2 3 4 inadequacies.
12. This person refuses to talk to some 1 2 3 4 members of the household.
13. This person only communicates with 1 2 3 4 other people through his/her parents.
14. This person isolates him/herself from 1 2 3 4 others.
15. This person threatens self-harm if his/her 1 2 3 4 demands are not met.
16. This person is unable to respond to 1 2 3 4 simple requests by authority figures.
17. This person is overly occupied with 1 2 3 4 his/her computer, smartphone, gaming, or the internet.
18. This person sleeps during the day and 1 2 3 4 remains awake throughout the night.
19. This person’s parents attempt to enforce 1 2 3 4 his/her independence.
20. This person is socially inept. 1 2 3 4
21. This person worries about his/her health. 1 2 3 4 102
22. This person relies on his/her parents’ resources (home, utilities, food, TV, internet, 1 2 3 4 etc.) for more than one year without working or attending school.
23. This person reports being bullied. 1 2 3 4
24. This person refuses to attend school even 1 2 3 4 though they are physically and mentally able to do so.
25. This person threatens others (like parents 1 2 3 4 or siblings) if his/her demands are not met.
26. This person is insensitive to others. 1 2 3 4
27. This person minimizes face-to-face 1 2 3 4 communication with others.
28. This person behaves rigidly. 1 2 3 4
29. This person seems unaware of his/her 1 2 3 4 feelings.
30. This person is inflexible. 1 2 3 4
31. This person exhibits little understanding 1 2 3 4 of himself/herself.
32. This person has a physical reaction to stress (headaches, sweating, upset stomach, 1 2 3 4 muscle pain).
APPENDIX J
EXPLORATORY CLUSTER ANALYSES
Two exploratory cluster analyses were performed to evaluate gender, age, length of dependency, and length of relationship on AED symptomology. The first analysis used target gender (categorical variable) and age of the targets (continuous variable) and
AED T scores served as the evaluation variable with four fixed clusters to produce younger/older male and younger/older female clusters along with concomitant AED symptomology. The model summary suggested good cohesion and separation (average silhouette =.8) with a cluster ratio of 5.8 between the largest cluster (young males, N =
58) and the smallest cluster (older males, N = 10). Order of predictor importance was
Target Age (1.00), Target Gender (0.74), and AED T Score (0.02). The highest AED symptomology was found in older women (N = 12, Mage = 42.2, MAED T score = 77.7), followed by younger men (N = 58, Mage = 25.5, MAED T score = 72.6), followed by younger women (N = 24, Mage = 25.8, MAED T score = 71.4), with older men (N = 10, Mage = 50.4,
MAED T score = 69.7) showing the least AED symptomology of the four clusters.
The second cluster analysis evaluated the effect of target gender, length of dependency, and length of relationship (the length of time the study participant had known the highly dependent adult child) upon AED symptomology using a two-step analysis with target gender and length of dependency (greater than 1 but less than 2 years, greater than 2 years but less than 5 years, 5 or more years) as categorical variables, and length of relationship in months between participant and target as continuous variable, and the 104
AED T scores as the evaluation variable, with six fixed clusters. The model summary suggested good cohesion and separation (average silhouette =.6) with a cluster ratio of
2.7 between the largest cluster (N = 24, 100% male, dependent greater than 5 years,
Mlength of relationship = 138.9 months) and the smallest cluster (N = 9, 77.7% males, dependent greater than 1 but less than 2 years, Mlength of relationship = 137.6 months). Order of predictor importance was Length of Dependence (1.00), Target Gender (0.49), Length of Relationship between participant and target (.19), and AED T Score (0.08). The highest AED symptomology was found in highly dependent women (N = 23, MAED T score
= 77.1, length of dependence greater than 5 years, length of relationship with participant
M = 218.7 months), followed by highly dependent men (N = 21, MAED T score = 75.2, length of dependence greater than 5 years, Mlength of relationship = 260.3 months), followed by highly dependent men (N = 21, MAED T score = 74.5, length of dependence greater than 5
years, Mlength of relationship = 69.3 months), followed by highly dependent men (N = 24, MAED
T score = 71.7, length of dependence greater than 2 but less than 5 years, Mlength of relationship =
138.9 months), followed by highly dependent women (N = 11, MAED T score = 67.6, length
of dependence greater than 2 but less than 5 years, M length of relationship = 180.9 months),
followed by the final cluster with the lowest AED symptomology composed of highly
dependent men (77.8%) and women (22.2%) (N = 11, MAED T score = 60.1, length of
dependence greater than 1 but less than 2 years, Mlength of relationship = 137.6 months). APPENDIX K
EXPLORATORY CORRELATIONS BETWEEN AED SUM AND INDIVIDUAL
PD SCALE ITEMS ON 9 STRONGEST CORRELATED PD SCALES
To evaluate the relationship between the AED scale and the different items on each of the strongly correlated CATI PD scales, as series of exploratory correlations between the AED scale scores and the individual items on the nine strongly correlated PD scales were performed.
Passive-aggressive items on the CATI and their correlations with AED scale scores are listed in Table K1. A closer examination of the individual passive-aggressive scale items shows a stronger relationship between the negative-affect (anger, resentment, persecution) and retribution (delay, obstruction, or inaction as a form of revenge) components of passive-aggressive PD and a weaker relationship with the employment/task-oriented component of the PD, as we might expect in someone suffering from AED who is very angry and resentful, but makes no attempt to support themselves through gainful employment in order to improve their circumstances.
Though not as strongly correlated as the passive-aggressive PD scale, the AED scale score was strongly correlated with the CATI borderline PD scale score, r = .59, p <
.01. Borderline items on the CATI and their correlations with AED scale scores are listed in Table K2. A closer examination of the individual borderline scale items shows a stronger relationship between the emotional dysregulation and violence components of borderline PD and a weaker relationship with the more ambiguous “display of emotion.” 106
Table K1
Zero-Order Correlations between Individual Items on the CATI Passive-Aggressive Scale and AED Scale Sum
Item r It takes very little to irritate him.† .50** He almost always gets angry when people criticize him.† .48** He almost always feels like people make unreasonable demands of him.† .47** He sometimes works slowly or does a bad job on a task if it is something he does not want .46** to do. People make him angry. .40** He becomes sulky or irritable if he is asked to do things that he does not want to do. .39** He often thinks he has done something well when he actually has done a bad job. .38** He refuses help or suggestions from others even if he needs it. .37** He believes in the saying, “Good things don’t last.” .37** He resents suggestions from others on how he can be more productive. .37** He feels like he has had more than his fair share of troubles in life. .36** He tends to be critical of people in positions of authority. .34** He fails to accomplish tasks even when he has the ability. .32** Praise and criticism bother him.† .21* He does not get enough appreciation from his work (home or job).† .21* He forgets to do things he is supposed to do. .21 He has difficulty starting projects on his own. .19 People often tell him that he has failed to do his share of the work.† .16 After he gets angry with someone, he is sorry and asks for forgiveness. −.15 He avoids or postpones making decisions. .13 He is very self-assured. −.13 He is a procrastinator (delays doing things until the last minute). .12 After he gets angry with someone, he is sorry and asks for forgiveness. −.06 He is not devoted to his job or work.† .02 * p < .05, ** p < .01, † These questions are reworded to reflect their reverse scoring.
This absence of a relationship between the AED construct and the display-of-emotions items may be due to the ambiguity of the term “emotional” which could also include displays of warmth, joy, sadness, or tenderness, resulting in a weak correlation because of the range of interpretation of the study participants.
Though not as strongly correlated as the passive-aggressive and borderline PD
scales, the AED scale score was also strongly correlated with the CATI paranoid PD
scale score, r = .58, p < .01. Paranoid items on the CATI and their correlations with AED
scale scores are listed in Table K3. A closer examination of the individual paranoid 107
Table K2
Zero-Order Correlations between Individual Items on the CATI Borderline Scale and
AED Scale Sum
Item r His moods change fairly quickly. .55** He is emotionally uncontrolled.† .53** He has more than his fair share of temper tantrums. .43** His anger gets out of control easily. .43** He emotions are fairly unstable.† .43** He says he feels empty or bored. .42** He is suicidal. .42** He is very impulsive in spending money, sex, drug use, shoplifting, reckless driving, or .40** binge eating. More than once he has hurt himself badly on purpose, like cutting his wrists, or smashing .39** his fist against a wall, etc. He is impulsive. .38** When he gets stressed, he acts unreal, weird, or strange. .38** He made more than one suicidal threat or gesture in his life. .31** He seems to be able to change his emotions quickly. .35** He is very afraid of being abandoned by someone. .35** He likes getting into physical fights.† .34** He tends to have intense but unstable relationships. .33** He gets depressed pretty quickly. .33** He frequently gets into physical fights. .25** He shows strong emotional feelings. .23* He wonders “who he is” much of the time. .14 He makes extreme efforts to avoid being alone. −.07 He is more emotional than other people.† −.05 He is an emotional person.† −.05 * p < .05, ** p < .01, † These questions are reworded to reflect their reverse scoring.
scale items shows a stronger relationship between jealousy, wariness, and interpersonal coldness components of paranoid PD and a weaker relationship with the display of warm emotion and neuroticism. Again, this may be due to the ambiguity of the term
“emotional” which could also include displays of warmth, joy, sadness, tenderness, resulting in a weak correlation because of the sensu lato interpretation of the term
“emotional” by the study participants.
108
Table K3
Zero-Order Correlations between Individual Items on the CATI Paranoid Scale and AED
Scale Sum
Item r He thinks people are out to get him, harm him or ruin him in some way. .57* He suspects people go out of their way just to annoy him. .53* He almost always gets angry when people criticize him.† .48* He tends to be suspicious of people. .47* He questions the faithfulness of his spouse or sexual partner. .45* He feels people are not as loyal to him as he wants. .45* He thinks people talk about him behind his back. .44* He is a cold person.† .43* He is a jealous person. .39* People make him angry. .39* He often expects to be exploited or harmed by others.† .38* He questions the loyalty of friends or associates. .35* He distrusts people more than he trusts them.† .33* He doesn’t forgive insults or slights quickly.† .32* When he is slighted or insulted by someone, he is quick to counterattack or show his anger. .31* He manages his life without help from others. −.29* He is reluctant to confide in others because he fears the information might be used against .25* him. He feels anxious most of the time.† .16 When he greets people, he doesn’t like to give them a hug.† .07 He is less emotional than other people. −.05 * p < .01, † These questions are reworded to reflect their reverse scoring.
Though not as strongly correlated as the passive-aggressive, borderline, and paranoid PD scales, the AED scale score was strongly correlated with the CATI
Narcissistic PD scale score, r = .57, p < .01. Narcissistic items on the CATI and their
correlations with AED scale scores are listed in Table K4. A closer examination of the
individual narcissistic scale items shows a stronger relationship between the lack of empathy and self-centeredness components of narcissistic PD and a weaker relationship with grandiose, flamboyant, or attention-seeking aspects of narcissism. Alexithymics are noted for their sparse fantasy life and poor imagination, which may account for this lack of grandiosity or a need to be associated with success, brilliance, or physical attractiveness. 109
Table K4
Zero-Order Correlations between Individual Items on the CATI Narcissistic Scale and
AED Scale Sum
Item r He thinks it is a fact of life that sometimes he has to step on people or hurt them to get what .51** he really wants. He acts like he is better than other people. .49** He almost always gets angry when people criticize him.† .48** He would lie to hurt someone if he feels they deserve it. .46** He is self-centered. .46** He feels his problems are unique and they can only be understood by someone really .43** “special.” He feels he is special and deserves favorable treatment from others. .42** He feels justified if he hurts or mistreats someone. .42** He becomes sulky or irritable if he is asked to do things that he does not want to do. .39** He thinks he was born with more abilities and talents than the average person. .36** He acts like he is a special person and deserves to be noticed for it. .36** He does not forgive insults or slights quickly.† .32** He is easily hurt by criticism or disapproval. .30** He is really annoyed or surprised when a person cancels an appointment with him for any .30** reason. He fantasizes a lot about being beautiful, powerful, or finding the perfect soul mate. .22* He wishes he had the successes other people have. .21* He does not get enough appreciation from his work (home or job).† .21* Both praise and criticism bother him.† .21* He is very envious of successful people. .21* He likes to get a lot of reassurance, approval, or praise from others. .19 He really hates giving money or gifts to others, even if he doesn’t gain anything from it.† .17 He enjoys getting a lot of admiration and attention from other people. .15 When he goes out, he likes people to notice him. .14 He fantasizes about being really successful, powerful, or brilliant. .12 He is very proud of his achievements. −.10 Physical attractiveness is very important to him. .06 * p < .05, ** p < .01, † These questions are reworded to reflect their reverse scoring.
Though not as strongly correlated as the passive-aggressive, borderline, and paranoid PD scales, the CATI obsessive-compulsive PD scale score was also strongly
correlated with the AED scale score, r = .57, p < .01, displaying the same correlation as
the narcissistic PD scale. Obsessive-compulsive scale items on the CATI and their
correlations with AED scale scores are listed in Table K5. A closer examination of the
individual obsessive-compulsive scale items shows a strong relationship between
dysthymic and intolerant components of obsessive-compulsive PD and a weaker 110 relationship with the attention to detail, control, and perfectionism aspects of obsessive- compulsive PD.
Table K5
Zero-Order Correlations between Individual Items on the CATI Obsessive-Compulsive
Scale and AED Scale Sum
Item r He doesn’t find much pleasure in life. .54** He gets very frustrated if he does not get what he wants immediately. .52** He is stubborn or rigid. .43** People often disappoint him. .41** He kept worn-out or worthless things even when they do not have sentimental value. .41** He is not impulsive in spending money, sex, drug use, shoplifting, reckless driving, or −.40** binge eating.† He tends to judge others harshly. .38** He rarely gives compliments to his family and co-workers.† .36** Often he does not complete a task because his standards are too high. .32** He fails to accomplish tasks even when he has the ability. .32** He usually insists others do things the way he wants them done. .31** He is easily hurt by criticism or disapproval. .30** He worries a lot. .28** When he is having a good time, he doesn’t like to show it.† .21* Praise or criticism bother him.† .21* He sets very high moral and ethical standards for himself and others. −.21* He repeatedly turns down chances to have a good time (like vacations). .20* He has difficulty starting projects on his own. .19 His perfectionism interferes with him completing a task on time. .17 He really dislikes giving money or gifts to others, even if he doesn’t gain anything from it.† .17 He does not like to let others do things because he is sure they will not do it correctly. .16 He is too conscientious. −.16 He has trouble finishing things on time because he spends too much time getting organized. .14 He avoids or postpones making decisions. .13 He likes to make complete plans for his vacation or leisure time. .07 He is very concerned about details, lists, or schedules before he begins a task. .06 He is an unemotional person. .05 He holds back his emotions and tender feelings. −.02 He is too devoted to his job or work. −.02 He likes to be really organized and has everything in order before he gets ready to do .02 something. * p < .05, ** p < .01, † These questions are reworded to reflect their reverse scoring.
Though not as strongly correlated as the passive-aggressive, borderline, paranoid, narcissistic, and obsessive-compulsive PD scales, the AED scale score was also strongly correlated with the CATI Sadistic PD scale score, r = .56, p < .01. Sadistic scale items on
the CATI and their correlations with AED scale scores are listed in Table K6. A closer 111 examination of the individual sadistic scale items shows a strong relationship between deceptive, lack of empathy, and manipulative components of sadistic PD and a weaker relationship with the childhood antisocial behavioral aspects of sadistic PD. This may be due in part to that fact that participants may not have known the target as a young person and therefore were left to speculate upon that person’s antisocial behavior as a child or adolescent.
Table K6
Zero-Order Correlations between Individual Items on the CATI Sadistic Scale and AED
Scale Sum
Item r He lies a lot. .53** He thinks it is a fact of life that sometimes he has to step on people or hurt them to get what .51** he really wants. He would lie to hurt someone if he feels they deserve it. .46** In a close relationship (spouse, significant other), he hates that person to have a lot of .45** freedom apart from him.† He has used harsh treatment or discipline to control someone in his care. .42** He feels justified if he hurts or mistreats someone. .42** He has used “scams” or “conned” people for profit or pleasure. .35** He tends to be critical of people in positions of authority. .34** Before the age of 15, he used a weapon in more than one fight. .32** He is amused by the suffering of animals or people. .32** Before the age of 15, he stole from others more than once (shoplifting, forgery, etc.). .31** Before the age of 15, he was physically cruel to people or animals. .30** He has often hit anyone in any of his adult relationships. .26** He has often humiliated or demeaned someone in public. .18 He likes stories or movies of violence, weapons, martial arts, injury, or torture. .15 He is an assertive person. .15 He has often frightened others to get them to do things he wants.† .11 * p < .05, ** p < .01, † These questions are reworded to reflect their reverse scoring.
Though not as strongly correlated as the passive-aggressive, borderline, paranoid, narcissistic, obsessive-compulsive, and sadistic PD scales, the AED scale score was also strongly correlated with the CATI antisocial PD scale score, r = .55, p < .01. Antisocial items on the CATI and their correlations with AED scale scores are listed in Table K7. 112
Like the highly correlated sadistic personality disorder scale, a closer examination of the individual antisocial personality disorder scale items shows a stronger relationship between the deceptive, lack of empathy, and manipulative components of antisocial PD and a weaker relationship with the interpersonal/sexual aspects of antisocial PD. This may be due in part to that fact that participants may not have detailed knowledge of the targets’ intimate behaviors.
Though not as strongly correlated as the passive-aggressive, borderline, paranoid, narcissistic, obsessive-compulsive, and sadistic PD scales, the AED scale score was also strongly correlated with the CATI schizotypal PD scale score, r = .55, p < .01, which shared the same correlation as the antisocial PD scale. Schizotypal items on the CATI and their correlations with AED scale scores are listed in Table K8. A closer examination of the individual schizotypal personality disorder scale items shows a stronger relationship between the paranoid, aloof, and distorted components of schizotypal PD and a weaker relationship with the psychotic aspects of schizotypal PD.
Though not as strongly correlated as the passive-aggressive, borderline, paranoid, narcissistic, obsessive-compulsive, sadistic, antisocial, and schizotypal PD scales, the
AED scale score was also moderately correlated with the CATI depressive PD scale score, r = .50, p < .01. Depressive items on the CATI and their correlations with AED scale scores are listed in Table K9. A closer examination of the individual depressive personality disorder scale items shows a strong relationship between the dysphoric components of the depressive PD and a weaker relationship with the self-referencing aspects.
113
Table K7
Zero-Order Correlations between Individual Items on the CATI Antisocial Scale and
AED Scale Sum
Item r He lies a lot. .53** He thinks it is a fact of life that sometimes he has to step on people or hurt them to get what he really .51** wants. It doesn’t take much to irritate him.† .50** He would lie to hurt someone if he feels they deserve it. .46** His anger gets out of control easily. .43** He feels justified if he hurts or mistreats someone. .42** He has used harsh treatment or discipline to control someone in his care. .42** Before the age of 15, he was a constant liar. .42** He is very impulsive in spending money, sex, drug use, shoplifting, reckless driving, or binge eating. .40** People make him angry. .39** He is rebellious. .38** He is impulsive. .38** It does not take much to frustrate him.† .37** Before the age of 15, he deliberately destroyed other people’s property (like vandalism or setting .37** fires). He has used “scams” or “conned” people for profit or pleasure. .35** He enjoys getting into physical fights.† .34** He is not afraid to do things that might get him arrested.† .33** He tends to have intense but unstable relationships. .33** He drifts from job to job. .32** Before the age of 15, he ran away from home over night more than once. .32** Before the age of 15, he often skipped school. .32** He has lived without a mailing address for long periods of time. .32** He has often personally hurt, neglected, or mistreated a child in his care. .32** He is reckless. .31** Before the age of 15, he stole from others more than once (shoplifting, forgery, etc.). .31** Before the age of 15, he was physically cruel to people or animals. .30** He has traveled about without a job, a clear goal, or a future plan. .29** Before the age of 15, he often started physical fights. .29** He has quit more than one job without having plans for his next job. .28** He has hit people in his adult relationships.† .26** He doesn’t pay back all loans and debts.† .26** He was a juvenile delinquent. .26** He frequently gets into physical fights. .25** He has often been a bad parent.† .20* He has humiliated or demeaned someone in public.† .18 He has gotten into trouble because of a drinking or drug problem. .16 Before the age of 15, he stole from someone face-to-face (like mugging or robbing someone). .16 He is not conscientious.† .16 He has not been sexually faithful to one person for more than one year.† .13 When a close relationship ends, he does not feel devastated or helpless.† −.12 He has often frightened others to get them to do things he wants them to do. .11 When he gets into a relationship, his partner is usually the one who ends up hurt.† .07 He has forced someone into sex with him.† .06 He often desires sex.† .02 He is not devoted to his job or work.† .02 * p < .05, ** p < .01, † These questions are reworded to reflect their reverse scoring.
114
Table K8
Zero-Order Correlations between Individual Items on the CATI Schizotypal Scale and
AED Scale Sum
Item r He tends to be suspicious of people. .49** He has no close friends other than in his family. .44** His style of speech is strange or vague. .43** He is not a warm person.† .43** He neither desires nor enjoys close relationships (including his family). .37** People have trouble understanding what he is trying to say. .36** He often talks out loud to himself. .33** He distrusts people more than he trusts them.† .33** He acts inappropriately, for example, he acts weird, strange, or too silly. .31** He thinks people on the radio are talking directly to him or about him. .29** Other people think he looks or acts odd, unusual, or eccentric. .29** He does not have a lot of friends.† .28** He likes to be silly and laugh. −.25* He is not very comfortable in social situations even if he knows the people there.† .23* He dislikes social gatherings where he must talk to a lot of people.† .23* He says his sense of taste or smell has changed. .18 He keeps himself aloof or distant from other people. .17 He is superstitious (believes in bad luck from black cats, the number 13, etc.). .16 He believes in special powers like clairvoyance, mental telepathy, or ESP. .16 He says he hears voices or sees things that are not really there. .15 When he greets people, he never gives them a hug.† .07 He has reported the presence of a force or person who is not actually there. .03 * p < .05, ** p < .01, † These questions are reworded to reflect their reverse scoring.
Table K9
Zero-Order Correlations between Individual Items on the CATI Depressive Scale and
AED Scale Sum
Item r He is unhappy most of the time. .49** He is a pessimist. .48** He feels worthless. .42** He tends to judge others harshly. .34** He worries a lot. .28** He feels guilty a lot of the time. .22* He is very self-critical. −.10 * p < .05, ** p < .01, † These questions are reworded to reflect their reverse scoring. APPENDIX L
EXPLORATORY ANALYSES OF AED GENDER DIFFERENCES
An exploratory analysis of elevated psychopathology (T scores on the AED scale, the 14 PDs scales, and executive dysfunction scale) was performed on the entire sample, followed by gendered subsamples. A T score of 60 was considered elevated but perhaps subclinical, while a T score of 70 was considered a highly elevated and likely clinical level of AED features. Percentage of subclinical and clinical psychopathology for AED,
14 CATI PDs, and executive dysfunction of the frontal lobes combined and by gender are listed in Table L1.
Table L1
Total and Gendered Percentage of Subclinical and Clinical Psychopathology for AED,
Executive Dysfunction of the Frontal Lobes, and 14 CATI PDs
Combineda Maleb Femalec T ≥ 60 T ≥ 70 T ≥ 60 T ≥ 70 T ≥ 60 T ≥ 70 AED 85.6d 58.7 83.8 54.4 88.9 66.7 Executive Dysfunction 86.5 56.7 88.2 57.4 83.3 55.6 Passive-Aggressive 88.5 57.7 88.2 52.9 88.9 66.7 Borderline 63.5 32.7 57.4 29.4 75.0 38.9 Paranoid 69.2 45.2 67.6 39.7 72.2 55.6 Narcissistic 61.5 33.7 55.9 27.9 72.2 44.4 Obsessive-Compulsive 29.8 5.8 26.5 4.4 36.1 8.3 Sadistic 67.3 44.2 67.6 47.1 66.7 38.9 Antisocial 78.6 57.7 77.9 57.4 80.6 58.3 Schizotypal 50.0 25.0 45.6 19.1 58.3 36.1 Depressive 46.2 9.6 41.2 5.9 55.6 16.7 Self-Defeating 67.3 17.3 61.8 5.9 77.8 38.9 Avoidant 37.5 15.4 38.2 11.8 36.1 22.2 Schizoid 48.1 22.1 48.5 23.5 47.2 19.4 Dependent 62.5 25.0 57.4 20.6 72.2 44.4 Histrionic 34.6 14.4 25.0 11.8 47.2 19.4 aN=104, bN=68, cN=36,dpercent of sample. 116
To evaluate gender differences in correlational relationships between the AED scale and the 14 CATI PD scales, the clinical study sample was divided by gender and a
series of zero-order correlations between the AED scale score and the 14 PD scales measured by the CATI were performed. Female and male participants exhibited atypical, dissimilar patterns in their Person product-moment correlations between the AED scale score and the 14 PD scales measured by the CATI. Females targets (see Table L2)
showed a higher correlation (r = .74) with passive-aggressive PD than their male counter
parts (r = .65) as well as a gender-atypical secondary pattern with narcissistic (typically reported as a PD with a high male prevalence) and paranoid secondary (both with r =
.64), followed by borderline and obsessive-compulsive PD (r = .60 and .58, respectively).
Table L2
Correlations between Female AED Scale Sum and 14 CATI PD Scale Sumsa
Personality Disorder M (SD) r
AED 82.56 (14.49) 1 Passive-Aggressive 67.50 (7.74) .74** Borderline 63.64 (10.15) .64** Paranoid 54.82 (9.98) .64** Narcissistic 76.36 (10.57) .60** Obsessive-Compulsive 72.64 (9.45) .58** Sadistic 40.06 (9.49) .52** Antisocial 113.22 (21.90) .51** Schizotypal 51.00 (9.64) .49** Depressive 17.78 (4.08) .48** Self-Defeating 54.69 (5.31) .47** Avoidant 45.31 (10.12) .46** Schizoid 19.42 (9.09) .40* Dependent 72.39 (11.19) .25 Histrionic 84.25 (9.59) .08 * p < .05, ** p < .01 (two-tailed), aN=36.
Although male participant AED scale scores also showed a primary affinity with passive-aggressive PD (see Table L3), their secondary correlations showed a gender- atypical pattern including borderline (typically reported as a PD with a high female 117
prevalence), sadistic, and antisocial (all three r = .59), appearing to suggest increased aggression and violence, decreased empathy, followed by obsessive-compulsive and schizotypal PD (both with r = .57).
Table L3
Correlations between Male AED Scale Sum and 14 CATI PD Scale Sumsa
Personality Disorder M (SD) r
AED 80.66 (15.88) 1 Passive-Aggressive 67.41 (7.83) .65* Borderline 60.03 (12.22) .59* Sadistic 40.71 (10.32) .59* Antisocial 113.84 (25.31) .59* Obsessive-Compulsive 70.18 (7.92) .57* Schizotypal 50.00 (8.84) .57* Paranoid 53.79 (10.04) .55* Narcissistic 71.69 (12.93) .55* Depressive 16.62 (3.70) .52* Self-Defeating 50.96 (4.89) .43* Dependent 67.84 (9.43) .38* Histrionic 76.87 (11.85) .35* Schizoid 19.81 (4.24) .34* Avoidant 44.34 (9.38) .33* * p < .01 (two-tailed), aN=68.
The atypical juxtaposition of borderline and narcissistic patterns across genders
bears closer inspection to reveal whether there may be an underlying pattern of gender
dysphoria associated with AED.
To evaluate the extent to which each gender displayed elevated and clinical levels
of AED, the 14 PDs, and executive dysfunction of the frontal lobes, exploratory Pearson
product-moment correlations were performed between each group’s mean percentage for
Male/Female T scores greater than 60 and Male/Female T scores greater than 70. For men
and women with T scores greater than 60, r = .91, p < .01. For men and women with T
scores greater than 70, r = .85, p < .01. 118
To evaluate the extent to which men and women differed on group mean scores
for the AED scale, the 14 PD scales, and executive dysfunction of the frontal lobes scale,
a series of 16 exploratory t tests were performed between each group’s mean scale T score. Three group means were significantly different, and one mean difference trended toward significance. Women showed significantly higher self-defeating PD scale T scores
(M = 66.27, SD = 8.37) than men (M = 60.39, SD = 7.70), t(102) = 3.601, p = .0005, with a medium correlation coefficient of effect size, r = .336. Women showed significantly higher histrionic PD scale T scores (M = 66.78, SD = 10.59) than men (M = 52.72, SD =
12.94), t(102) = 3.218, p = .002, with a medium correlation coefficient of effect size, r =
.304. Women showed significantly higher dependent PD scale T scores (M = 66.76, SD =
10.48) than men (M = 62.30, SD = 9.24), t(102) = 2.199, p = .03, with a small correlation coefficient of effect size, r = .213. Of interest, women trended toward significance with higher narcissistic PD scale T scores (M = 66.16, SD = 11.34) than men (M = 61.15, SD =
13.88), t(102) = 1.861, p = .07. No significant gender differences were found regarding executive dysfunction of the frontal lobes. 119
APENDIX M
UCCS INSTITUTIONAL REVIEW BOARD APPROVAL LETTER