1. Attachment: Attachment Categories & Psychiatric Disorders 19th Nov 2010 Dr Helen Brotherton 19th Nov 2010 Dr Helen Brotherton

2. 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 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

3. 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 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

4. 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 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

5. 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 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

6. 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 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

7. 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 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

8. 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 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

9. 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 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

10. 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  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

11. 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 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

12. 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 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

13. 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  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

14. 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 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

15. 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 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

16. 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  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

17. 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 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

18. 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)  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)

19. 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 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

20. 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 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

21. 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 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

22. 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 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

23. 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 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

24. 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  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

25. 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 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