Assessing Attachment Representations in Adolescents: Discriminant Validation of the Adult Attachment Projective Picture System

A Pilot Study on the Influence of Maternal Attachment Representations on Maternal Heart Rate Mediated by Perceived Stress

Past findings have suggested that there is a link between attachment representations and reactions towards stress (subjective and physiological). The aim of this study was to examine the mediating effect of perceived stress on the association between attachment representation and physiological changes, specifically heart rate. As part of a long-term study investigating the transgenerational transmission of childhood maltreatment, n = 163 mothers participated in multiple assessments. The Adult Attachment Projective Picture System (AAP) was used to measure maternal attachment representation, categorizing individuals as securely or insecurely attached. Perceived daily stress was assessed using the Perceived Stress Scale 14 (PSS-14), and maternal baseline heart rate (HR) was measured via electrocardiography during a laboratory visit. The results revealed that the representation of secure attachment had a significant reducing effect on both the mother's perceived daily stress and heart rate. Furthermore, the association between secure attachment representation and heart rate was mediated by perceived stress. This study emphasizes the role of attachment representation in maternal well-being, highlighting its impact on stress and physiological responses.

Personality Disorders and Attachment Trauma in Adolescent Patients with Psychiatric Disorders

This study examined how personality disorders (PD) differ with respect to gender, attachment status and traumatic childhood experiences in adolescent psychiatric inpatients. In particular, we investigated attachment-related traumatic material underlying adolescent PD. Our sample consisted of 175 inpatient adolescents aged 14 to 18 years (77% female, Mage = 15.13, SD = 1.35; 23% male, Mage =14.85, SD = 1.41). Thirty-nine patients (22%) fulfilled the diagnostic criteria for a PD according to the SCID-II PD: 51% avoidant, 13% obsessive-compulsive, 13% antisocial, 19% borderline, 2% paranoid and 2% histrionic. In the total sample, eighty-three (47%) of our inpatients were classified with an unresolved attachment status using the Adult Attachment Projective Picture System (AAP). We did not find any significant gender differences for patients with and without a PD. Our results revealed a higher percentage of unresolved attachment status in patients with a PD. The in-depth analysis of the total sample showed that patients with a PD demonstrated more traumatic material in their attachment interviews indicating a greater severity of attachment trauma. Furthermore, patients with a PD reported higher scores on emotional and physical neglect. Intervention strategies targeting traumatic attachment-related themes might be useful to treat adolescents with PD.

Unresolved attachment and identity diffusion in adolescence

This study examined the severity of unresolved attachment underlying adolescent identity diffusion. Our sample consisted of 180 inpatient adolescents aged 14 to 18 years (77% female, M age = 15.13, SD = 1.35; 23% male, M age = 14.85, SD = 1.41) and 84 age-matched non-clinical adolescents (52% female, M age = 16.14, SD = 1.21; 48% males, M age = 15.98, SD = 1.07). We used the Adult Attachment Projective Picture System (AAP) interview to assess attachment representations and the Assessment of Identity Development in Adolescence (AIDA) questionnaire to evaluate the severity of identity diffusion. Our results demonstrate a higher amount of unresolved attachment and identity diffusion in the patient sample than in the control sample. Furthermore, patients with an unresolved attachment status scored higher on identity diffusion than those with no unresolved attachment pattern. Interestingly, this was not found in the control group. Furthermore, patients with a greater severity of unresolved attachment showed the highest maladaptive identity development scores. Psychotherapeutic interventions integrating attachment-related aspects might be useful to treat young people with identity diffusion.

Attachment-Related Differences in Emotion Regulation in Adults: A Systematic Review on Attachment Representations

In recent years, there has been an increase in the prevalence of mental disorders connected with affective dysregulation and insecure attachment. Therefore, it is even more important to understand the interplay between an individual's attachment representation and patterns of emotion regulation. To our knowledge, this is the first systematic review to examine this association. PsycInfo, PsyArticles, and PubMed were searched for studies that examined attachment-related differences in emotion regulation in adults. To examine the unconscious attachment representation, only studies using the Adult Attachment Interview or the Adult Attachment Projective Picture System were included. Thirty-seven peer-reviewed studies (with a total of 2006 subjects) matched the PICO criteria. Emotion regulation was measured via four objective approaches: autonomic nervous system, brain activity, biochemistry, or nonverbal behavior. Across all measurements, results reveal a significant correlation between attachment representation and emotion regulation. Secure attachment correlates consistently with balanced emotion regulation, whereas it is impaired in insecure and dysfunctional in unresolved attachment. Specifically, unresolved individuals display counterintuitive responses and fail to use attachment as a resource. Insecure-dismissing attachment is associated with an emotionally deactivating strategy, while on a physiological, biochemical, and nonverbal level, emotional stress is still present. There is still a lack of studies examining preoccupied individuals. In addition to interpreting the results, we also discuss the risk of bias, implications for psychotherapy and coaching, and an outlook for future research.

A systematic review of measures of adult disorganized attachment

BACKGROUND

Disorganized attachment has been identified as an important factor in the development and maintenance of mental health problems. Further research is required to understand the mechanism by which this attachment pattern predisposes individuals to develop, and maintain, personal and social difficulties and mental health problems utilizing valid and reliable measurement tools. The assessment of adult disorganized attachment is therefore important for both applied psychologists and researchers.

METHOD

We conducted a systematic review using the COSMIN guidelines to identify and critically appraise instruments which measure adult disorganized attachment. A systematic database search was performed using MEDLINE, EMBASE, Web of Science, PsychInfo and CINHAL in accordance with PRISMA guidelines.

RESULTS

Database searching provided 5757 results, with 18 measures identified across 27 eligible papers which were critically evaluated. Measurement properties were promising for the Childhood Disorganization and Role Reversal Scale, Psychological Treatment Inventory-Attachment Styles Scale, Attachment Style Questionnaire - Short Form and the Adult Attachment Interview. However, overall, due to inconsistent quality of methodology and reporting of results, it is challenging to reach sufficient conclusions and suggestions regarding the best instrument to use to measure adult disorganized attachment.

CONCLUSION

The Childhood Disorganization and Role Reversal Scale, Psychological Treatment Inventory-Attachment Styles Scale. Attachment Style Questionnaire-Short-Form and Adult Attachment Interview are the best available measures of disorganized attachment in adulthood. This review highlights the need for further psychometric testing of existing measures, or development of new instruments, grounded in sound methodology.

Identifying Risk and Resilience Factors in the Intergenerational Cycle of Maltreatment: Results From the TRANS-GEN Study Investigating the Effects of Maternal Attachment and Social Support on Child Attachment and Cardiovascular Stress Physiology

Introduction

Childhood maltreatment (CM) is a developmental risk factor and can negatively influence later psychological functioning, health, and development in the next generation. A comprehensive understanding of the biopsychosocial underpinnings of CM transmission would allow to identify protective factors that could disrupt the intergenerational CM risk cycle. This study examined the consequences of maternal CM and the effects of psychosocial and biological resilience factors on child attachment and stress-regulatory development using a prospective trans-disciplinary approach.

Methods

Mother-child dyads (N = 158) participated shortly after parturition (t 0), after 3 months (t 1), and 12 months later (t 2). Mothers' CM experiences were assessed at t 0, attachment representation at t 1 and psychosocial risk and social support were assessed at t 1 and t 2. At t 2, dyads participated in the Strange Situation Procedure (SSP). Children's attachmen status were classified as organized vs. disorganized, including their level of disorganized behavior, and heart rate (HR) and respiratory sinus arrhythmia (RSA) were recorded as stress response measures of the autonomic nervous system. Maternal caregiving during SSP was assessed using the AMBIANCE scale. Child's single nucleotide polymorphisms rs2254298 within the oxytocin receptor (OXTR) and rs2740210 of the oxytocin gene (OXT) were genotyped using DNA isolated from cord blood.

Results

Maternal CM experiences (CM+) were significantly associated with an unresolved attachment status, higher perceived stress and more psychological symptoms. These negative effects of CM were attenuated by social support. As expected, maternal unresolved attachment and child disorganized attachment were significantly associated. Maternal caregiving did not mediate the relationship between maternal and child attachment but influenced children's HR and RSA response and disorganized behavior. Moreover, the rs2254298 genotype of the OXTR gene moderated the stress response of children from mothers with CM. Children carrying the rs2740210 risk allele of the OXT gene showed more disorganized behavior independent from maternal CM experiences.

Conclusion

We replicated and extended existing CM and attachment models by co-examining maternal attachment, social support, and child genetic susceptibility on child attachment and cardiovascular stress regulation. The findings contribute to an extended understanding of risk and resilience factors and enable professionals to target adequate services to parents and children at risk.

Secure Attachment Representation in Adolescence Buffers Heart-Rate Reactivity in Response to Attachment-Related Stressors

To date, we know very little about the effects of the differences in attachment classifications on the physiological correlates of stress regulation in adolescent age groups. The present study examined for the first time heart rate (HR) and heart rate variability (HRV) during an attachment interview in adolescents. HR and HRV data were collected during a baseline assessment as well as during the administration of the Adult Attachment Projective Picture System (AAP) in a community-based sample of 56 adolescents (26 females and 30 males, mean age = 16.05 years [SD = 1.10]). We additionally used the Adult Attachment Interview (AAI) in 50% of our sample to test the convergent validity. Adolescents with a secure attachment representation showed a higher HRV from baseline to the AAP interview compared to those with an insecure-dismissing (Ds) and the unresolved group. A comparison between the two insecure attachment groups showed no significant difference related to HR and HRV. Cohen’s Kappa (κ = 0.81) revealed an almost perfect agreement between the AAP and the AAI for the four-group classification. Our results indicate that adolescents with a secure attachment representation are more capable of dealing with attachment-related distress which is represented in higher HRV during an attachment interview.

[Attachment-Related Affect Regulation of Mothers in a Psychiatric Parent-Child Ward - A Case Study]

Attachment researchers propose that the term affect regulation is associated with attachment-related defensive processes resulting from attachment experiences with primary caregivers. They serve to regulate attachment-related inner states. The Adult Attachment Projective Picture System (AAP) is a reliable and valid tool to classify attachment patterns and it allows to assess these attachment-related defensive processes. It provides information about the defensive processes that help clinicians to understand complex symptoms and interaction patterns in the parent-child relationship that can be integrated into psychiatric treatment. The present case study deals with a mother of a child with a feeding disorder. We will illustrate how information on attachment-related affect regulation can successfully be integrated into psychotherapeutic intervention in a psychiatric parent-child ward.

Non-suicidal self-injury and attachment trauma in adolescent inpatients with psychiatric disorders

This study examined how non-suicidal self-injury disorder (NSSID) differs with respect to mental disorders, gender and attachment status in adolescent psychiatric patients. In particular, we analyzed attachment-related traumatic material underlying adolescent NSSID. Our sample consisted of 137 in-patient adolescents aged 12 to 18 years (73% female, M_age = 15.09, SD = 1.44; 27% male, M_age = 14.65, SD = 1.53). Forty-four patients (32.1%) fulfilled the diagnostic criteria for NSSID according to the DSM-5 and ninety-three patients (67.9%) did not meet diagnostic criteria for NSSID. Our results revealed a higher prevalence of NSSID in female patients and in patients with mood disorders. In the total sample, 52% of our in-patients were classified with an unresolved attachment status. The diagnostic subgroup analysis demonstrated a higher percentage of unresolved attachment status only in patients with eating disorders and NSSID. However, our in-depth analysis of the total sample revealed that patients with NSSID demonstrated more traumatic material in their attachment interviews indicating a greater severity of attachment trauma. In particular the theme of helplessness in interpersonal conflicts left them in a state of attachment dysregulation. Intervention strategies targeting traumatic attachment-related themes might be useful to reduce the number of adolescents engaging in NSSI.

Unresolved Attachment Mediates the Relationship Between Childhood Trauma and Impaired Personality Functioning in Adolescence

The present study investigates the mediating effect of attachment trauma on the relationship between childhood maltreatment and personality functioning in 199 adolescents (12-18 years) using a novel approach of an in-depth analysis of attachment-related traumatic contents during an attachment interview (AAP). Our findings demonstrate that adolescents with a high amount of traumatic attachment-related material show a lower resilience when facing traumatic childhood experiences, resulting in a greater severity of personality dysfunction. In particular, the associations between emotional abuse and neglect and the domains of identity, empathy, self-direction, and intimacy were mediated by the severity of attachment trauma. These results advance our understanding of the different nuances of attachment-related traumatic material and how they might shape personality structure in an adolescent age group.

Attachment-Related Representations and Suicidal Ideations in Nonsuicidal Self-Injury Adolescents with and without Suicide Attempts: A Pilot Study

OBJECTIVES

Consistent with the debate surrounding the association between nonsuicidal self-injury (NSSI), suicidal intent, and suicidal behavior, and between NSSI and dysregulation processes, we attempted to analyze suicide intent and emotion dysregulation in NSSI adolescents, in the framework of the attachment representations and exploring these clues of emotion dysregulation characteristics of insecure attachment. Furthermore, we intended to focus on these attachment-related segregated systems regarding death and suicidal ideations, to explore how differently they would characterize self-injuring adolescents with and without suicide attempts.

METHODS

Thirty-four NSSI inpatient adolescents, 17 with suicide attempts, 17 without suicide attempts, and 17 healthy controls (age 11-17) were assessed using Adult Attachment Projective, which allows for the classification of attachment status and related emotion dysregulation and segregated systems.

RESULTS

The majority of the NSSI group with and without suicide attempts showed unresolved (disorganized) attachment-related representations and clues of damaged reflective functions, whereas only the NSSI with suicide attempts showed clues of impaired interpersonal relationships. The two clinical groups used words expressing suicidal intent, whereas the healthy group did not.

CONCLUSIONS

Therapists are encouraged not to underestimate suicidal ideation in NSSI regardless of whether or not they have already attempted suicide.

Insecure and Unresolved/Disorganized Attachment in Patients With Psychogenic Nonepileptic Seizures

BACKGROUND

Psychogenic nonepileptic seizures (PNES) are still poorly understood and difficult to treat. Attachment theory could add new aspects to the understanding of the multifactorial genesis and maintenance of PNES and the therapeutic needs of this patient group.

OBJECTIVE

The aim of the present study is to systematically assess attachment in adult patients with PNES with a focus on the role of unresolved/disorganized attachment.

METHODS

A cross-sectional design was chosen to compare patients with confirmed PNES (n = 44) and healthy controls (n = 44) matched for gender, age, and education. Attachment was assessed using the Adult Attachment Projective Picture System. Psychometric questionnaires included the Childhood Trauma Questionnaire; Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) axis II disorders, Patient Questionnaire; the Somatoform Dissociation Questionnaire; and the Patient Health Questionnaire.

RESULTS

We found significantly less secure (P = 0.006) and more unresolved/disorganized (P = 0.041) attachment classifications in the PNES group. Among patients with PNES, 7% were classified secure and 43% were classified unresolved/disorganized. Patients with an unresolved attachment representation were significantly more likely to be screened positive for personality pathology in the Structured Clinical Interview for DSM-IV axis II disorders, Patient Questionnaire (P = 0.03) and to report more emotional abuse in the Childhood Trauma Questionnaire (P = 0.007) than patients with other attachment classifications.

CONCLUSIONS

Our findings suggest that unresolved/disorganized attachment might be the predominant attachment style in patients with PNES and might be associated with more severe personality pathology. This could be of therapeutic relevance. The present study is the first to assess adult attachment in patients with PNES using a semi-structured interview in comparison to matched healthy controls.

Genes and environment in attachment

In the last two decades, there has been increasing research interest in disentangling the contribution of genetic and environmental factors to individual differences in attachment, and in identifying the genes involved in shaping attachment. Twin studies suggest that as attachment changes during the course of development, genetic factors may play a progressively more important role, while shared environmental effects might decrease. However, most of this literature is limited by low power, measurement issues, and cross-sectional design. The findings of molecular genetic studies are, overall, inconclusive. The literature on main genetic effects and gene-by-environment interactions on attachment is filled with inconsistent and unreplicated findings. Also, most studies are underpowered. Challenges for future research are to identify the unshared environmental mechanisms involved in shaping attachment, and to better elucidate the genes involved and their interaction with the environment. Some pioneer studies suggested that the incorporation of epigenetic processes into G × E interaction models might represent a promising future way for investigating the complex, dynamic interplay between genes, environment, and attachment.

Attachment disorder and attachment theory - Two sides of one medal or two different coins?

INTRODUCTION

Currently, attachment quality and attachment disorder exist in parallel, but the mutual association is still insufficiently clarified. For policy makers and clinical experts, it can be difficult to differentiate between these constructs, but the distinction is crucial to develop mental-health services and effective treatment concepts. We aimed to investigate the association between attachment representations (AR) and attachment disorders (AD), including Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) in children aged between 5 and 9.

METHODS

A total of 135 children aged between 5 and 9 years (M=7.17 years, SD=1.40, 63% male) and their primary caregivers participated in the study. Children were interviewed with the story stem method to assess AR, and the primary caregiver completed diagnostic interviews and questionnaires on mental disorders, AD, emotional and behavioral problems, and intelligence and development.

RESULTS

The prevalence of AR in children with AD was 28.6% for the 'secure' form of AR, 17.1% for the 'insecure-avoidant' form, 25.7% for the 'insecure-ambivalent' form, and 28.6% for the 'disorganized' form. Prevalences of the various AR forms did not differ statistically significantly, indicating that AR is conceptionally distinct from AD. Children with disorganized attachment scored significantly lower on language and intelligence skills than children with secure attachment. AD was significantly associated with a higher number of comorbidities, emotional and behavioral problems, and lower language skills.

CONCLUSIONS

Longitudinal studies using standardized assessment instruments are needed to systematically provide comparable and reliable empirical findings to improve current understanding of AR and AD as well as their etiological models.

Attachment Patterns Affect Spiritual Coping in Palliative Care

Research has shown that spiritual coping is essential for palliative care patients in enhancing quality of life and that attachment patterns affect the emotional well-being of the terminally ill. This is the first study evaluating how spiritual coping and attachment are associated in palliative care patients. Four different attachment patterns-secure, dismissive, preoccupied, and unresolved-were examined, as well as how they relate to three different spiritual coping strategies-search, trust, and reflection. In a cross-sectional, correlative design, 80 patients were recruited from German palliative care wards and hospices. Attachment patterns were determined using the Adult Attachment Projective System and spiritual coping strategies by SpREUK questionnaire, measuring spiritual and religious attitudes in dealing with illness. The results indicate that there is an association between attachment style and spiritual coping. Preoccupied patients had the lowest score in spiritual coping, with the strategy "reflection" being significantly lowest (t = 2.389, P = .019). Securely and dismissively attached patients presented equally high scores, raising the question of what mechanisms underlie spiritual coping. Furthermore, the unresolved group scored high in spiritual coping. Heightening awareness for ways in which attachment styles influence spiritual coping can contribute significantly to the quality of life in terminally ill patients, enabling health care professionals to tailor to individual needs in this vulnerable stage of life.

Use of the Adult Attachment Projective Picture System in the formulation of a case of an adolescent refugee with PTSD

Forced displacements and their psychosocial consequences in adolescent refugees and their families have received increasing attention in recent years. Although supportive family relations play a key role in buffering the impact of traumatization in adolescents, parental ability to provide such is often subject to extreme pressure. Under conditions of forced dislocation and fear, maladaptive interpersonal strategies in the parent-child relationships may develop, contributing to the onset of psychopathology. We explore new aspects of attachment-related issues for the understanding and treatment of adolescent refugees who have experienced multiple traumas in their childhood. We used a multimethod assessment battery including the Adult Attachment Projective Picture System (AAP), the Structured Clinical Interview, the Youth Self Report and the Wechsler Intelligence Scale in an adolescent boy with post-traumatic stress disorder (PTSD). Our subject was an adolescent refugee from the Middle East who demonstrated an unresolved attachment when confronted with loss and fear. His responses on the AAP evoked aspects of insecure-unresolved attachment, including his belief that it is not safe to trust in attachment figures, his limited access to traumatic attachment experiences, his impaired ability to take concrete actions when dealing with threatening attachment situations and the unintentional role-reversal shed new light on our understanding of his traumatic experiences, family functioning and psychopathological symptoms. Our results demonstrate the utility of the AAP in an adolescent refugee with PTSD by expanding our knowledge of a diverse range of experiences across the interpersonal, cognitive, cultural and developmental contexts that formed the basis for an individualized treatment plan.

Disorder-specific attachment characteristics and experiences of childhood abuse and neglect in adolescents with anorexia nervosa and a major depressive episode

For the first time, the present study investigates disorder‐specific attachment characteristics and childhood trauma in adolescent inpatients with anorexia nervosa (n = 30, girls/boys: 28/2, age: M = 14.84, SD = 1.20), a major depressive episode (n = 30, girls/boys: 27/3, age: M = 15.14, SD = 1.50), and controls (n = 60, girls/boys: 44/16, age: M = 16.10, SD = 1.20). We used the Structured Clinical Interview to diagnose Axis I disorders, the Adult Attachment Projective Picture System to classify attachment representations, and the Childhood Trauma Questionnaire to assess child maltreatment. Our findings demonstrate an overrepresentation of the unresolved attachment status in the patient samples. A one‐way analysis of variance succeeded by Bonferroni post hoc tests indicated that adolescents with anorexia nervosa show more isolation and dissolution of boundaries between life and death when confronted with situations of solitude. Although they report moderate to severe levels of traumatic childhood experiences, they tend to minimize those. Adolescents with a major depressive episode report higher levels of emotional abuse and neglect in their childhood, leaving them in a state of failed protection and danger during attachment distress. Integrating these attachment‐related characteristics into specific psychotherapeutic interventions might be associated with a better outcome in that age group.

High Prevalence of Insecure Attachment in Patients with Primary Hypertension

Hypertension is a major cardiovascular (CV) risk factor and is predicted by heightened CV reactivity to stress in healthy individuals. Patients with hypertension also show an altered stress response, while insecure attachment is linked to a heightened stress reactivity as well. This is the first study aiming to assess attachment representations in patients with primary hypertension and to investigate their CV responses when their attachment system is activated. We studied 50 patients (38 men, 12 women) with primary hypertension. The Adult Attachment Projective Picture System (AAP), a widely used and validated interview, was performed to measure the patients' attachment representations, and to activate their attachment system. Blood pressure and heart rate were measured after 10 min at rest prior to and directly after the AAP interview. Mood and state anxiety were assessed using the Multidimensional Mood State Questionnaire (MDBF) and the State Trait Anxiety Inventory-State (STAI-S) before and after the experiment. The prevalence of insecure attachment (dismissing, preoccupied, unresolved) in hypertensive patients was predominant (88%), while in non-clinical populations, only about 50% of individuals had insecure attachment patterns. Blood pressure (p < 0.001), heart rate (p = 0.016), and rate pressure product (p < 0.001) significantly increased in response to the attachment interview. Secure attached patients showed the highest rise in systolic blood pressure (p = 0.020) and the lowest heart rate compared to the other attachment groups (p = 0.043). However, attachment representation showed no significant group or interaction effects on diastolic blood pressure (DBP) and rate pressure product. Insecure attachment was highly over-represented in our sample of patients with primary hypertension. Additionally, a robust CV response to the attachment-activating stimulus was observed. Our data suggest that insecure attachment is significantly linked to primary hypertension, which implies the need for further investigations to evaluate attachment insecurity as a possible risk factor for hypertension.