|Year : 2014 | Volume
| Issue : 2 | Page : 117-126
Psychological profile of women with infertility: A comparative study
Shuvabrata Poddar1, Nilanjana Sanyal2, Urbi Mukherjee3
1 Department of Clinical Psychology, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand, India
2 Department of Psychology, University of Calcutta, Kolkata, West Bengal, India
3 Department of Applied Psychology, University of Calcutta, Kolkata, West Bengal, India
|Date of Web Publication||18-Feb-2015|
Department of Clinical Psychology, Central Institute of Psychiatry, Kanke, Ranchi, Jharkhand - 834 006
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: An endeavour to probe into the psychological profile of infertile women in a comparative stance with the fertile women is not very common. This study is an attempt to explore the possible non-apparent personality factors which contribute to the unexplained pain of infertility. Methods: The main objectives of the present study were (a) to examine whether infertile women are different from fertile women in terms of selected psychological variables- narcissistic components, dimensions of attachment style and uses of defensive manoeuvres; and (b) whether the primary infertile women (n=18) are different from the secondary infertile women (n=12) with respect to those variables. A total of 60 individuals (30 infertile women and 30 matched fertile women) were assessed through Attachment Style Questionnaire (ASQ), Narcissistic Personality Inventory (NPI) and Defense Style Questionnaire (DSQ-40). General Health Questionnaire (GHQ) was administered on to the fertile women to rule out the psychiatric morbidity. Results: Findings revealed that infertile women group differed from fertile women group with respect to narcissism, dimensions of attachment style and uses of defense mechanism. The primary infertile group also showed marked difference from the secondary infertile group with respect to those variables. Conclusions: This study endeavours to enrich the knowledge regarding the personality dynamics of infertile women to design psychotherapeutic programme to aid their well-being, help them to cherish the flavour of parenthood and improve their quality of life.
Keywords: Attachment style, defensive manoeuvres, infertility, narcissistic components
|How to cite this article:|
Poddar S, Sanyal N, Mukherjee U. Psychological profile of women with infertility: A comparative study. Ind Psychiatry J 2014;23:117-26
Marriage is the most intimate of all human interactions. At its heart, marriage is an interpersonal relationship between a man and a woman; conceptually marriage can supply love and affection, emotional support and loyalty, stability and security, companionship, friendship, sexual fulfillment and material well-being. For many couples and individual, the ability to conceive and give birth to a child is a key to lifelong ideas about meaning of life. The expectation that a married couple will eventually have children is profound in our society. It is not only frustration but also devastating for many to want to have children but cannot. Baker and Robert  notes in her book, healing the infertile family that parenting is the bond that seals the generation together and the opportunity to pass along the life experiences to the next generations is what, for many of us, gives life its meaning. These feelings seem to stem from the fact that the desire and drive to have children is deeply rooted in our human culture as well as in our biology. Bearing children and parenting are often the foundations around, which the couples have built a loving and committed relationship. The inability to conceive or give birth to a healthy child can threaten one's sense of identity, places one's values and motivations for parenthood in question, and often forces people to re-evaluate the meaning of their relationship as a couple. The condition of infertility usually leads to a life crisis. As a result, many who experience infertility are thrust into a state of emotional disequilibrium.
Infertility primarily refers to a biological inability of a man or a woman to contribute to conception. Infertility may also refer to the state of a woman who is unable to carry a pregnancy to full term. Reproductive endocrinologists, the doctors specializing in infertility,  consider a couple to be infertile if:
- The couple has not conceived after 12 months of contraceptive free intercourse if the female is under the age of 34
- The couple has not conceived after 6 months of contraceptive free intercourse if the female is over the age of 35 (declining egg quality of females over the age of 35 account for the age-based discrepancy as when to seek medical intervention)
- The female is incapable of carrying a pregnancy to term.
Types of infertility
A couple that has tried unsuccessfully to have a child for a year or more is said to be subfertile, meaning less fertile than a typical couple.
Primary and secondary infertility
Couples with primary infertility have never been able to conceive while, on the other hand, secondary infertility is difficulty conceiving after already having conceived but had an abortion or miscarriage or carried a normal pregnancy. Technically, secondary infertility is not present if there has been a change of partners. 
In some cases, both the man and woman may be infertile or subfertile, and the couples' infertility arises from the combination of these conditions. In other cases, the cause is suspected to be immunological or genetic; it may be that each partner is independently fertile, but the couples cannot conceive together without assistance.
In about 15% of cases, the infertility investigation will show no abnormalities. In these cases, abnormalities are likely to be present but not detected by current methods.
Although various biogenic, physiological and endocrine factors have been identified as direct or potential causes of infertility, it is just 30 years back when health professionals start believing that there was a direct psychological basis underlying many cases of infertility. This condition was thought to be the direct results of emotional conflicts around femininity or masculinity or a conflicted or ambivalent relationship with one's mother. Men and women were both seen as experiencing psychosexual maladjustments that resulted in the inability to conceive. However, published research work on the core psychological components in relation to infertility is limited. Systematic studies show that there is definitely no scientific evidence for a "fixated" desire for a child, a "psychological blockage" or a specific relationship pattern of the infertile couple being responsible for infertility, nor is there any such evidence that giving up the desire for a child helps to increase the rate of conception. In a small number of cases, psychological factors are indeed the sole cause for fertility disorders. With the advancement in psychoneuroimmunology, recent studies on the linkage between psychological stress and physiological mechanisms have indicated correlations between distress and reproductive restraints. Although several authors have suggested an important pathogenic role of psychosocial factors in "functional infertility," the extent to which depression, anxiety and expressed emotional patterns correlate to infertility is not yet clear. Differences emerged in the degree of psychopathology between organic and functional infertility subjects and fertile controls. In women, factors like anxiety, depression and tendency to anger and suppression, fear of pregnancy have emerged as predictors of infertility. ,
A group of Indian researchers set out to evaluate the personality features of people who were infertile and found that there was a marked difference between fertile and infertile people-woman with functional infertility (i.e. no organic) had low scores on cooperativeness and self-directedness than women with organic infertility.  One study showed that the infertile women are significantly more vulnerable than men to stimuli related to reproduction (such as the sight of a pregnant woman) and are more likely, as a result, to have painful intrusive thoughts related to infertility. 
Sense of personal failure, guilt and shock are also found to be important factors that hinder the process of a successful pregnancy.
Hence, conceptual clarification and literature suggest that the manifested psychological aspects of infertility have its source rooted in the personality of individuals while, at the same time, the psychological point of view acknowledges the role and importance of other organic and societal factors.
The present study is an attempt to probe into the issue from some selected core aspects of personality. The selected variables of the study are as follows:
Attachment is a binding affection, an emotional tie between people. The usual connotation is that kind of emotional relationship is infused with dependency: Persons rely on each other for emotional satisfaction. 
Began with the work of Bowlby,  later Ainsworth et al.  formulated the concept of maternal sensitivity to infant signals and its role in the development of infant-mother attachment pattern.
The four attachment styles based on two "working models" of self-schema and social self and interpersonal trust are secure attachment style, fearful-avoidant attachment style, preoccupied attachment style and dismissing attachment style.
Researchers have found these links between attachment styles and relationship patterns in adulthood.  Adults with avoidant and anxious attachment styles were more likely to be depressed than securely attached adults  and women with anxious or avoidant styles and men with an avoidant attachment style were more likely to have unwanted but consensual sexual experiences than securely attached adults.  It has also been found that women suffering from infertility of unknown biological cause tend to have an avoidant attachment style. 
Narcissism means love of oneself and refers to the set of character traits concerned with self-admiration, self-centeredness, and self-regard. Primary narcissism, in classical psychoanalysis, refers to the early stage of development when libido is overly invested on the self or the ego or more simply to the body. The stage is considered normal in very young, should it persists to adulthood, it is usually classified as a neurosis and is generally characterized by a love of self that precedes, if not precludes, love of others. Secondary narcissism refers to the love of self that results from withdrawn of the libido from objects and persons and investing it on oneself. Thus, it is an emotional investment onto the self. Kernberg  uses the term narcissism to refer to the role of self in the regulation of self-esteem.
Defense mechanisms are psychological strategies brought into play by various entities to cope with reality and to maintain self-image. Healthy persons normally use different defenses throughout life. An ego defense mechanism becomes pathological only when its persistent use leads to maladaptive behavior such that the physical and/or mental health of the individual is adversely affected. The purpose of the ego defense mechanisms is to protect the mind/self/ego from anxiety, social sanctions or to provide a refuge from a situation with which one cannot currently cope.
The specific objectives of the present study are as follows:
- To examine whether infertile women are different from fertile women in terms of selected psychological variables-dimensions of attachment style, narcissistic components and uses of defensive manoeuvres; and
- Whether the primary infertile women are different from the secondary infertile women with respect to those above-mention ed variables.
| Materials and Methods|| |
A total of 60 women aged 28-38 years, having minimum educational qualification of a graduate degree and maximum doctorate, Indian citizens, belonged to higher-middle socioeconomic strata and not having any chronic physical and organic illness, with no history suggestive of substance dependence were selected by means of purposive sampling. The participants were classified in two groups: (a) Infertile group (comparable group 1, N 1 = 30), and (b) fertile group (comparable group 2, N 2 = 30). The infertile group comprised 18 women with primary infertility (comparable group 1A) who never conceived and 12 women with secondary infertility (comparable group 1B) who had at least one miscarriage and did not conceive thereafter. The participants were assigned to the comparable group 1 only after the diagnosis of infertility was made by a gynecologist. The group was matched on the basis of duration of infertility (tried to have an issue for minimum 3 years) and duration of marriage (married for at least 3 years). They were under pharmacological treatment as per requirement during the study due to ethical reasons. For the comparable group 2, the participants were matched on the basis of a number of children (at least having one issue) and duration of marriage (married for at least 3 years). Presence of any sort of psychiatric morbidity in this group was ruled out using appropriate screening tool and participants having history of menopause were excluded.
The study followed cross-sectional study design using purposive sampling method.
The variables under investigation were - Attachment styles, narcissism, and defense mechanism.
Information schedule, prepared for this study was used to elicit information on sociodemographic details like location of stay, age, mother tongue, educational qualification, age of marriage, duration of marriage etc., For comparable group 1, information on duration of infertility, course of infertility, treatment of infertility, history of abortion/miscarriage (if any), history of any physical, psychiatric illness, endocrinal disturbances and substance use were also noted; and for comparable group 2, number of children and interaction pattern with the children and general ambience of the family.
General health questionnaire-28 
This 28-item questionnaire was used as a screening test to rule out presence of psychiatric morbidity in comparable group 2. Each of the items has four response alternatives. The split half reliability is 0.97. Its sensitivity and specificity are 1 and 0.88 respectively.
Attachment style questionnaire 
Inspired by the Bartholomew and Horowitz,  Feeney et al.  through factor-analysis developed this 40-item self-report questionnaire with five dimensions: Confidence, preoccupation with relationships, relationships as secondary (to achievement), discomfort with closeness, and need for approval. The only dimension of secure attachment is confidence. The other four are dimensions of various insecure attachment styles. The internal consistency (Cronbach's alpha) was reported to be 0.80 and test-retest reliability over a 10 weeks period was found to be 0.76. 
Narcissistic personality inventory 
It is a 40-item measure that assesses narcissism as a normally distributed personality trait.  The narcissistic personality inventory (NPI) distinguishes seven different aspects of narcissism namely - Authority, self-sufficiency, superiority, entitlement, exhibitionism, exploitativeness, vanity. The Cronbach's alpha for internal consistency of the NPI was 0.81. Convergent and discriminant validity were found to be satisfactory. 
Defense style questionnaire 
It is a self-report measure to assess possible conscious derivatives of defense mechanisms, Andrews et al.  simplified the instrument into forty questions related to 20 defense mechanisms among which four defenses are related to the mature factor (sublimation, humor, anticipation and suppression), four are related to the neurotic factor (undoing, pseudo-altruism, idealization and reaction formation) and 12 are related to the immature factor (projection, passive aggression, acting out, isolation, devaluation, autistic fantasy, denial, displacement, dissociation, splitting, rationalization and somatization). The internal consistency of the mature, neurotic and immature defense styles was 0.70, 0.61 and 0.83 respectively. Additionally results revealed that the three defense styles had acceptable split-half reliability and test-retest reliability coefficients.
Participants meeting required criteria were subjected to provide consent on the first hand, before administration of the study tools. The clinically diagnosed infertile clients (comparable group 1) were selected from a gynecological clinic (who gave consent) after being examined and diagnosed by the chief gynecologist. Rapport was established with all the participants at first, and the confidentiality of their information was assured. Participants under comparable group 2 were screened through the general health questionnaire-28 (GHQ-28) to rule out presence of psychiatric morbidity (GHQ-28 scores < 4). Information was collected from selected participants of both the groups using information schedule, and they were then assessed through attachment style questionnaire, NPI and defense style questionnaire.
Statistical operations of the collected data were done using Statistical Package for Social Sciences version 16.0.(IBM, New York ) 
Significant differences between infertile and fertile group (comparable group 1 and comparable group 2 respectively) with respect to the selected variables-attachment styles, narcissism, defense mechanism, were verified with t-tests for independent samples of equal size. Further, the significant differences between the two subgroups under comparable group 1 - Primary and secondary infertile groups (comparable group 1A and comparable group 1B respectively) were verified with t-tests for small, independent samples of unequal size. In addition, descriptive statistics of mean and standard deviations were also computed.
| Results|| |
The findings of the data collected from the participants comprising the present study sample can be summarized under two sections: (A) Results showing differences between the two groups-fertile and infertile (comparable group 1 and comparable group 2 respectively) with respect to the different variables under consideration; and (B) Results showing differences between the two subgroups of infertile women - Primary and secondary infertile group (comparable group 1A and comparable group 1B respectively) according to the study variables.
Results showing differences between the two groups fertile and infertile (comparable group 1 and comparable group 2 respectively)
The results of [Table 1]a indicate that there is a significant difference in the dimensions of attachment namely confidence, discomfort with closeness and preoccupation with relationships between the fertile and infertile group with respect to their means. The infertile group have high discomfort with closeness and are more preoccupied with relationships whereas the fertile group is far more confident about their relationships as compared to the infertile women.
The results [Table 1]b indicate that there is a significant difference between the means of the two groups in terms of the degree of narcissism and its dimensions-authority, self-sufficiency, superiority, exhibitionism, exploitativeness, vanity and entitlement. Overall the infertile women are far more narcissists as compared to the fertile women.
Further, the results of [Table 1]c suggest that there is a significant difference between the means of the two groups fertile and infertile in the use of mature defenses. The infertile women use more mature defenses as compared to the fertile ones. In case of use of individual defenses, the means of the two groups differ significantly; in case of two defenses sublimation and idealization, the infertile women use both sublimation and idealization to a greater extent as compared to the fertile women.
Results showing differences between the two subgroups of infertile women-primary and secondary infertile group (comparable group 1A and comparable group 1B respectively)
The results of [Table 2]a indicate that the secondary infertile group has a high need for approval than the primary infertile group.
Findings from [Table 2]b indicate that there is a significant difference between the means of the primary and secondary infertile groups in the dimensions of exhibitionism and entitlement. Overall, the primary infertile women are more narcissistic than the secondary infertile women.
| Discussion|| |
According to the objectives of the present study, statistical analysis of the data attempted to probe into the fact whether there exits any significant difference between infertile and fertile women and between primary infertile and secondary infertile women with respect to their profiles of dimensions of attachment styles, narcissism and uses of defense mechanisms. Some findings of the study have brought out certain basic differences with respect to their selected variables amongst the two groups.
Discussion on comparative profile of infertile and fertile women with respect to the selected variables
Dimensions of attachment style
The results indicate that the infertile women have higher discomfort with closeness than the fertile women. As they seem to have a feeling of inadequacy, incompleteness they tend to avoid closeness with people and relationship. It has also been found from research that women suffering from infertility of unknown biological cause tend to have an avoidant attachment style. 
The results also indicate that the infertile women are much more preoccupied with their relationships than the fertile women. As they seek social support and acceptance, they seem to have more dependence need that leads to their preoccupation with the relationships. Moreover, since they do not have child to look after and is involved in the context, their thought preoccupation remains at basic habit.
The fertile women, on the other hand, are high on confidence and positive self-image. They tend to feel secure about their relationships. Secure individuals express trust in their partners and are able to engage in collaborative problem solving in their lives.  A person with secure attachment tends not only to have a warm relationship with their parents but also provided warmth and security for his or her offspring  - this is positive parent prototyping. The fertile women have a secure base by virtue of having a child that gives a boost in their confidence. Researches show that individuals with a fearful avoidant attachment style are negative about self and other people, so they avoid the fear of rejection by minimizing interpersonal closeness.  They also report less intimacy. 
There is a negative feeling about self in the infertile women which is extended to negative feeling about others because of their childlessness. This can also contribute to their higher degree of discomfort with closeness.
Narcissism and its Correlates
The results indicate that the infertile group of women are significantly more narcissistic than the fertile group of women. In case of the infertile group, narcissism seems to act as a defense. Their sense of insufficiency probably is being covered by a superior self-manifestation resulting in higher degrees of narcissism in them. Among the different domains of narcissism the infertile groups, as the results indicate, manifest significantly higher degrees of authority, self-sufficiency, sense of superiority, exhibitionism, exploitativeness, vanity and higher sense of entitlement in comparison to the fertile group. Infertile women lack the social support and acceptance which fertile are bestowed with by virtue of their motherhood. As a result, they exhibit themselves in order to draw the attention of others and reassure their position in the society. Again the lack of social support in their lives prompts the infertile women to search for an anchorage within themselves rather than in the world around. Thus, they tend to show a higher degree of self-sufficiency as well. Infertile women have no control whatsoever on their inability to attain motherhood. They, therefore, try to compensate for this lack of control over the other aspects of their lives as well as of the lives of other people around them. Further as it can be seen from Akhtar's  study, narcissists consider themselves to be special and better than others. The tendency to control the lives of others or exercise ones authority over others may be said to arise. This also justifies their higher sense of being superior over others and to exploit them.
The infertile women lack social support and have problems in their relationship due to the inability of bearing a child that induces a feeling of shame in them. To hide that shame of not having lived a life of their inner hopes, wishes and aspirations they tend to develop a high sense of entitlement as noted by other researches. 
Another fact may be that as the infertile women are more defensively narcissistic, and people with high narcissism have deteriorated the capacity for interpersonal relationships, narcissism seems to be a source of constant interpersonal problems.  In addition, interactions with people may be detrimentally affected by projected feelings of envy aggression that prevent the narcissistic individual from forming deep and close attachments, and may lead him/her to withdraw into "splendid isolation." 
Use of defense mechanisms
The results indicate that the infertile women use mature defenses more than the fertile women. The infertile women have a feeling of inadequacy because of their childlessness. So they want to get rid of their anxiety through constructive and mature ways by employing sublimation to channelize the distress arising from the ungratified need of motherhood or parenthood and also by idealizing (idealization) somebody who also is not enjoying biological motherhood but is still happy and content with their life.
The fertile women do not seem to have prominent inadequacy and they have less anxiety components regarding their lives and relationships as they have a child so they don't have any preference over any particular defense style or individualistic defense mechanisms. They tend to mix and match and use each one of them appropriately at times they are needed to be used.
Thus, the findings in an integrated fashion signify that as the infertile women are more unhealthily narcissistic, they have many negative qualities but according to some researches narcissism in its healthy form is also a precursor to creativity, wisdom and empathy.  The situation basically signifies the existentialistic inauthentic personality frame of infertile women. Their narcissism seems to be a veil over their inner cries and distress. Moreover, narcissism may be fuelled by criticism and rejection and less social support which leads them to an over concentration of psychological interest on self.  In other way, excessive narcissism may have affected the infertile women's relationships and attachment with others leading to discomfort with closeness with others and their self-preoccupation, whereas the fertile women are less narcissist and are more secure with their relationships and are also confident about their relationship bonds.
Discussion on comparative profile of the primary infertile and secondary infertile women with respect to the selected variables
Dimensions of attachment style
The results indicate that the secondary infertile women have a very high need for approval as compared to the primary infertile women. The secondary infertile women have to face a lot of criticism and rejection from the society and family due to their inability to carry their pregnancy successfully and further not being able to conceive. However, on the other dimensions of attachment styles, no significant differences between the two groups were found.
In the context owing to their fertility resources primary group seems to have more emotional stability and do not opt for more than required degree of social approvals.
Narcissism and its aspects
The results indicate that the primary infertile women are more narcissistic than the secondary infertile group. As infertility is a pain in itself, and it is a social taboo, it affects the persons' mental process. In a defensive structure/frame, narcissism helps the primary infertile women to maintain their self-esteem through over-concentration on self. According to researches, narcissism is a self-oriented mental activity, which is necessary for robust self-esteem, personal cohesiveness and stability.  The primary infertile women are also higher in the domains of exhibitionism and entitlement as compared to the secondary infertile women. The primary infertile women face a lot of rejection as they have not been able to conceive at all so they strive for personal attention but when it is not possible otherwise they exhibit themselves to be at the center of attention. The inability to conceive at all induces a feeling of shame and inadequacy in the primary infertile women; to hide the feeling of not lived the life in a true sense as they wanted, they have a higher sense of entitlement than secondary infertile women. 
Use of defense mechanisms
The results indicate that the secondary infertile women use the immature defenses considerably to a larger extent as compared to the primary infertile women. This may be due to the stress, lack of social support and feeling of shame over their infertility to conceive or carry a successful pregnancy that results in distress in the interpersonal context. 
The secondary infertile women use the defenses anticipation, pseudo-altruism, and somatization to a larger extent as compared to the primary infertile women.
Anticipation - The secondary infertile women have had many negative incidents including the loss of a child that may have led them to anticipate the outcomes of a situation before and try to cope with it successfully.
Pseudo-altruism - The ungratified urge of having a child is partially satisfied by helping others and gaining approval from others.
Somatization - As in our society the physiological problem is more attended as compared to the psychological problem they tend to somatize more.
Altogether, the primary infertile women are more defensively narcissistic, being more exhibitionistic and have a high sense of entitlement than the secondary infertile women. As the secondary infertile women have a very high need for approval as compared to the primary infertile women, they cannot accept rejection in relationship and getting clubbed with their less narcissistic tendency, this may lead to higher need for approval from others and relationships by employing immature defenses like anticipation, pseudo-altruism, somatization, more than the primary infertile women as that immature defenses function specifically as adaptations to distress that arise in interpersonal contexts. 
Acknowledging the limitations of the study, it can be highlighted from the findings that the present study would aid the treatment process of infertility and help health professionals to plan intervention including the bio-psycho-social aspects so that complexities of the infertility treatment can be facilitated and smoothed a little.
| References|| |
Baker LA, Robert EE. When every relationship is above average: Perceptions and expectations of divorce at the time of marriage. Law Hum Behav 1993;17:439-50.
Guzick DS, Silliman NP, Adamson GD, Buttram VC Jr, Canis M, Malinak LR, et al
. Prediction of pregnancy in infertile women based on the American Society for Reproductive Medicine's revised classification of endometriosis. Fertil Steril 1997;67:822-9.
Coelingh Bennink HJ. Method of treating or preventing infertility in a female mammal and pharmaceutical kit for use in such method. U.S. Patent No. 8,236,785; 7 Aug, 2012.
Stanton AL, Lobel M, Sears S, DeLuca RS. Psychosocial aspects of selected issues in women's reproductive health: Current status and future directions. J Consult Clin Psychol 2002;70:751-70.
Rebecca AD, Splittorff NK. Male infertility and impotence resources on the web. Health Care Internet 2002;6:39-45.
Domar AD, Clapp D, Slawsby E, Kessel B, Orav J, Freizinger M. The impact of group psychological interventions on distress in infertile women. Health Psychol 2000;19:568-75.
Agarwal A, Gupta S, Sharma R. Oxidative stress and its implications in female infertility - A clinician's perspective. Reprod Biomed Online 2005;11:641-50.
Bowlby J. Attachment, Attachment and Loss. Vol. I. London: Hogarth; 1969. [Pelican edition; 1971].
Ainsworth MD, Blehar MC, Waters E, Wall S. Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Erlbaum; 1978.
Goldberg S. Recent developments in attachment theory and research. Can J Psychiatry 1991;36:393-400.
Hankin BL, Kassel JD, Abela JR. Adult attachment dimensions and specificity of emotional distress symptoms: Prospective investigations of cognitive risk and interpersonal stress generation as mediating mechanisms. Pers Soc Psychol Bull 2005;31:136-51.
Gentzler AL, Kathryn AK. Associations between insecure attachment and sexual experiences. Pers Relatsh 2004;11:249-65.
João MR, Moreira JM. Attachment Style and Infertility of Unknown Biological Cause: An Elusive Relationship? 17 th
International Conference of the European Health Psychology Association, Kos, Greece; 2003.
Kernberg OF. Borderline Conditions and Pathological Narcissism. New York: Aronson; 1975.
Goldberg DP, Hillier VF. A scaled version of the General Health Questionnaire. Psychol Med 1979;9:139-45.
Feeney J, Noller P, Hanrahan M. Assessing adult attachment. In: Sperling MB, Berman WH, editors. Attachment in Adults: Clinical and Developmental perspectives. New York: Guildford Press; 1994.
Bartholomew K, Horowitz LM. Attachment styles among young adults: A test of a four-category model. J Pers Soc Psychol 1991;61:226-44.
Raskin RN, Hall CS. A narcissistic personality inventory. Psychol Rep 1979;45:590.
Bond MP. The development and properties of the defense style questionnaire. In: Conte HR, Plutchik R, editors. Ego Defenses: Theory and Measurement. New York: Wiley; 1995. p. 202-20.
Andrews G, Singh M, Bond M. The Defense Style Questionnaire. J Nerv Ment Dis 1993;181:246-56.
Levesque R. SPSS Programming and Data Management: A Guide for SPSS and SAS Users. 4 th
ed. Chicago, III: SPSS Inc.; 2007.
Lopez-Ibor JJ. Narcissism. New Oxford Textbook of Psychiatry. New York NY:Oxford University Press; 2002.
Brennan KA, Shaver PR. Dimensions of adult attachment, affect regulation, and romantic relationship functioning. Pers Soc Psychol Bull 1995;21:267-83.
Mikulincer M, Shaver PR, Pereg D. Attachment theory and affect regulation: The dynamics, development, and cognitive consequences of attachment-related strategies. Motiv Emot 2003;27:77-102.
Tidwell MC, Reis HT, Shaver PR. Attachment, attractiveness, and social interaction: A diary study. J Pers Soc Psychol 1996;71:729-45.
Akhtar S. Broken Structures: Severe Personality Disorders and Their Treatment. Northvale, NJ: Jason Aronson; 1992.
Kohut H. The Restoration of the Self. Madison, CT, New York: International University Press; 1977.
Burnstein B. Narcissistic personalities in DSM-III. Compr Psychiatry 1982;23:409-20.
Stolorow RD. Toward a functional definition of narcissism. Int J Psychoanal 1975;56:179-85.
McMahon C, Barnett B, Kowalenko N, Tennant C. Psychological factors associated with persistent postnatal depression: Past and current relationships, defence styles and the mediating role of insecure attachment style. J Affect Disord 2005;84:15-24.
[Table 1], [Table 2]