Attachment: Attachment Categories & Psychiatric

Disorders

30th Nov 2012

Dr Helen Brotherton

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

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)

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

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

incompetentCummings & Cicchetti (1990) hypothesized that:-• iv) having a psychologically unavailable carer was similar

to experience actually losing a carer

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

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

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 commonBipolar Depression:-• Research is limited, but suggest more likely to be

classified as ‘dismissing’ than other depressions

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

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

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

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

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

Attachment States of Mind & Dissociative Disorders:

ResearchResearch 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

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

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

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

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

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

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)

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

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

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

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

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

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

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