1. Attachment: Attachment Categories & Psychiatric Disorders 30 th Nov 2012 Dr Helen Brotherton

2. Adult Attachment + AMH Presentations Research - AAI Most research exploring links between attachment patterns & the later development of AMH conditions has utilized the Adult Attachment Interview [AAI] This research tool looks at not only the attachment history, but also how the interviewee is able (or not) to talk about their primary attachment figures

3. Adult Attachment Types - AAI Classifications Adult Attachment Interview (AAI) (Main):- i) Secure-autonomous - logical, concise, coherent ii) Insecure Avoidant - unelaborated, childhood amnesia (life seen as good, but don’t know why) iii) Insecure Ambivalent - rambling, inconclusive iv) Disorganized - disjointed, broken narratives Clinical use/research base - see Steele & Steele (2008)

4. Attachment Categories & Mood Disorders Mood Disorders Some show predominantly internalizing symptoms- self-blame & self-deprecation -> consistent with ‘preoccupied’ states of mind Some show predominantly externalizing symptoms- interpersonal hostility -> consistent with ‘dismissing’ states of mind

5. Attachment & Mood Disorders: Theoretical Links Bowlby (1980) hypothesized 3 major childhood events likely to be linked with adult depression:- i) parental death- hopelessness, lack of control ii) child unable (despite many attempts) to form secure relationships with caregivers iii) parent gives child messages they are unlovable or incompetent Cummings & Cicchetti (1990) hypothesized that:- iv) having a psychologically unavailable carer was similar to experience actually losing a carer

6. Childhood attachment-related events & later depression Strong empirical support:- Insecure attachment (ambivalent & avoidant) predicts depression in adolescence Death of parent in early childhood puts individual at risk for later depression (Harris, Brown et al studies) Loss by separation has been associated with less severe but more angrier depression Loss itself is important, but as important is subsequent experiences with caregivers

7. Attachment States of Mind & Depression: Research Research findings:- Depressed women in depression-only category were in all 3 categories (F,E,D) All BPD women classified as ‘preoccupied (E)’ but only 50% of depressed women Major depression associated with ‘autonomous’- related to episodic depression ‘Earned-secure’ vs ‘continuous secure’-> ‘earned-secure’ women had more depressive symptoms

8. Attachment- Unipolar & Bipolar Depression: Research Unipolar Depression:- Distinctions appear between chronic dysthmia and major depressive episodes Differences may exist between self-blaming (internalizing) vs other-blaming (externalizing) types of depression Comorbidity is common Bipolar Depression:- Research is limited, but suggest more likely to be classified as ‘dismissing’ than other depressions

9. Attachment & Anxiety Disorders: Theoretical Links Bowlby (1973) hypothesized that all forms of anxiety (GAD, phobias) related to anxiety about availability of attachment figure,with parental over-control or rejection, ie:- i) child worries about parental survival; ii) child worries about rejected/abandoned; iii) child feels need to remain at home; iv) parent has difficulty letting child go

10. Childhood attachment-related events & later anxiety Empirical support for links:- Panic disorder clients more frequently had early loss of carer or inadequate caregiving Agoraphobia clients reported more childhood separation anxiety & early separations, ie from mother or thru divorce GAD clients reported more parental rejection and role reversal than controls Social anxiety clients reported importance of family history of mental illness &early separations

11. Attachment States of Mind & Anxiety: Research Research findings:- Most adults with anxiety disorders classified as ‘preoccupied’[E] (Fonagy et al) But, also disproportionately represented in ‘Unresolved to loss/trauma’[U] category 63% of PTSD clients classified as ‘Unresolved to trauma’, therefore unresolved status (not preoccupied) predictive of PTSD diagnosis

12. Attachment & Dissociative Disorders: Theoretical Links If parent cannot protect or is source of threat, child may experience threat as overwhelming & enter dissociative state One predictor of dissociative symptoms in adolescence & into adulthood is disorganized attachment in infancy, as measured on Strange Situation test Strongest predictor of adolescent dissociative symptoms incl maternal neglect, disrupted affective communication with mother

13. Childhood attachment-related events & adult Dissociation Empirical support for links:- Again, disorganized attachments to caregivers in infancy, leading to later abuse risk Incidence of abuse is high (up to 97% of cases) 62% of adults with dissociative disorders had mothers who lost a close relative or suffered other traumatic event within 2yrs of child’s birth

14. Attachment States of Mind & Dissociative Disorders: Research Research findings:- No studies showing distribution of attachment categories per se Work at Clinic for Dissociative Studies suggests multiple organizational strategies Nature of dissociative disorder though means that behaviour on ‘Unresolved’ status resembles dissociative phenomena

15. Attachment & Eating Disorders: Theoretical Links Bowlby (1973) suggested link between child receiving messages that they are inadequate and out-of-control and difficulty feeling lovable or with adult independence Children receiving these message may develop more externalizing symptoms, as they turn away from their own distress Cole-Detke & Kobak (1996) suggested eating disorders reflect controlling the world thru eating, whilst directing attention away from own distress

16. Childhood attachment-related events & adult eating disorders Complicated but relatively consistent links: Women with anorexia typically describe both parents negatively (many studies) Fathers often described as emotionally unavailable and rejecting Mothers often described as domineering, overprotective & perfectionistic Parents described as acting in ways which thwart efforts at independence- Parents found to offer double communications- support & undermining

17. Attachment States of Mind & Eating Disorders: Research Contradictory research findings:- Women with eating disorders ‘nonautonomous’ (insecure)-95% on AAI- 79% ‘dismissing’ [D] Women with eating disorders & depression most frequently as ‘preoccupied’[E], similar to depression findings But, Fonagy et al found 64% of people with eating disorders classified as ‘preoccupied’ But 13 out of 14 classified as ‘Unresolved to trauma/loss’ [U] when category used

18. Attachment & Schizophrenia: Theoretical and Childhood Links Research favours more biological links than environmental effects in schizophrenia development in later life Strong hereditability of schizophrenia Studies exploring family environments have looked at ‘expressed emotion’ Difficult to tease out cause or effect in differing parental behaviours to child who later develops schizophrenia- Familial influences more strongly related to relapse

19. Attachment States of Mind & Schizophrenia: Research Research to be treated with caution:- ‘lapses’ on AAI could reflect difficulty with thoughts/discourse in schizophrenia Could reflect over-representation of ‘nonautonomous’ categories, esp ‘Unresolved’ Tyrrell et al found 89% classified as ‘dismissing’[D], but 44% as ‘unresolved’ [U] when this category was included

20. Attachment & Borderline PD: Theoretical Links Main & Hesse hypothesized trauma in absence of supportive carers predisposes people to borderline/ dissociative disorders Maintenance of un-integrated models of self & other occurs if caregivers behave in frightened or frightening way BPD internal models of others as inconsistent & self as inconsistently valued reflect insecure & disorganized early relationships (Fonagy et al)

21. Childhood attachment-related events & BPD in adulthood Compelling evidence:- Family histories very similar between BPD and dissociative disorders, esp early abuse Study- 81% of clients with BPD report experiencing or witnessing physical/ CSA 57% of these report events before 7yrs Study- high rates of prolonged separations, emotional neglect, mothers who suffered a loss in 2yrs and early maltreatment in people with BPD

22. Attachment States of Mind & BPD: Research Strong research support:- If ‘Unresolved’ category is used, studies show high rates for BPD (89%; 75%) Barone (2003) compared BPD clients vs controls:- for BPD clients- 7% [62%- controls] autonomous; 23% [10%] preoccupied; 20% [21%] dismissing; & 50% [7%] unresolved

23. Attachment States of Mind & BPD: Research BPD and Minnesota longitudinal study:- [Carlson, Egeland & Sroufe, 2009]- looked for early predictors of BPD symptoms at 28yrs…… Attachment disorganization.20* –12-18months Maltreatment.20** –12-18months Maternal hostility & boundary disssolution.42*** –42months

24. Attachment States of Mind & BPD: Research BPD and Minnesota longitudinal study:- [Carlson, Egeland & Sroufe, 2009]- looking for early predictors of BPD symptoms at 28yrs…. Family disruption related to father presence.21** –12-64months Family life stress.29*** –3-42months

25. Attachment States of Mind & BPD: Research BPD and Minnesota longitudinal study:- Early adolescent predictors- suggest disturbances in self-representation in early adolescence may mediate link between attachment disorganization and personality disorder Diathesis-stress theory of BPD [Fonagy] - theories suggest interaction between child’s genetic vulnerability and adverse experiences in family environment

26. Attachment & Antisocial PD: Theoretical and Childhood Links Bowlby (1973) suggested children experiencing parental separation & threats of abandonment, they feel intense anger If it proves dangerous to direct this anger towards parents, others may become targets Prolonged caregiver separations, fathers’ antisocial behaviour & neglectful mothers have all been linked to adult Antisocial PD Physical abuse or harsh disciple also been linked

27. Attachment States of Mind & Antisocial PD: Research Empirical evidence suggests:- Antisocial PD is associated with ‘unresolved’(50%) and ‘dismissing’(50%) Rare category of ‘Derogation of attachment’ in ‘dismissing’ figured highly High numbers rated as ‘cannot classify’ [CC] (15-37%), meeting criteria for multiple, incompatible categories Violent men likely to be non-autonomous or CC