Attachment representations, patterns of emotion regulation, and social exclusion in patients with chronic and episodic depression and healthy controls

Excitatory brain stimulation over the left dorsolateral prefrontal cortex enhances voluntary distraction in depressed patients

BACKGROUND

While implicit distraction could ameliorate negative feelings in patients with major depressive disorders (MDD), it remains unclear whether patients could benefit from explicit, voluntary distraction. Meanwhile, though the dorsolateral prefrontal cortex (DLPFC) is established as a crucial brain region involved in attentional control, the causal relationship between the DLPFC and voluntary distraction is unexplored in patients.

METHODS

Combing explicit distraction and transcranial magnetic stimulation (TMS), this study investigated whether TMS-activated DLPFC facilitates voluntary distraction in MDD patients. Eighty patients diagnosed with current MDD underwent either active (n = 40) or sham (n = 40) TMS sessions, followed by receiving negative social feedback from other patients, during which they were requied to use distraction strategy to down-regulate their painful feelings. Electroencephalogram was recorded during the task.

RESULTS

Both the subjective emotional rating and the amplitude of late positive potential showed that depressed patients successfully down-regulate their negative emotions via voluntary distraction, and the TMS-activated left DLPFC produced a larger benefit of emotion regulation compared to the sham TMS group. Results also revealed that while emotion regulation effect was negatively associated with depressive symptoms in the sham TMS group, this correlation was largely diminished when patients' left DLPFC was activated by TMS during the voluntary distraction.

CONCLUSIONS

These findings demonstrated that distraction is valuable for emotion regulation in MDD patients and they could be beneficial in voluntary distraction by activating their left DLPFC using neural modulation techniques. This study has valuable implications for clinical treatement of emotional dysregulation in MDD patients.

Attachment mediates the link between childhood maltreatment and loneliness in persistent depressive disorder

BACKGROUND

A central concept of attachment theory is that early experiences with close attachment figures shape the way we interact with and relate to other social partners throughout life. As such, early experiences of childhood maltreatment (CM) have been suggested as a key precursor of adult insecure attachment representations. As CM has been linked to feelings of loneliness in adulthood, this study examines whether insecure attachment could explain the relationship between CM and loneliness. Also, the moderating role of a diagnosis of persistent depressive disorder (PDD) is investigated, a disorder characterized by high levels of CM and loneliness.

METHOD

60 patients with PDD (DSM-5) and 60 gender- and age-matched non-clinical control participants (NC) completed self-report questionnaires measuring attachment, loneliness, and CM. Mediation analyses (PDD as a moderator) were performed.

RESULTS

PDD patients reported higher levels of CM, attachment anxiety, attachment avoidance, and loneliness than NC. CM was positively associated with loneliness in both groups. Mediation analyses demonstrated that the relationship between CM and loneliness was mediated by avoidant, but not anxious attachment, regardless of a diagnosis of PDD.

LIMITATIONS

Caution when interpreting these results is crucial as the study lacked a clinical control group, relied on self-report measures, and the cross-sectional design limits the ability to draw causal inferences.

CONCLUSIONS

All constructs studied were present to a greater degree in PDD. Above, findings provide initial evidence that avoidant attachment may explain the relationship between CM and loneliness. Potentially, adult avoidant attachment may lead to and maintain feelings of loneliness, regardless of PDD.

Identifying potential mechanisms between childhood trauma and the psychological response to the COVID-19 pandemic in Germany: a longitudinal study

Childhood maltreatment (CM) has been associated with adverse psychosocial outcomes during the pandemic, but the underlying mechanisms are unclear. In a prospective online study using baseline and 10-week follow-up data of 391 German participants, we applied multiple mediation analyses to test to what extent COVID-19 perceived stressors mediate the association between CM and later adverse psychosocial outcomes compared to established mediators of rumination and insecure attachment. We also explored the relative importance of different COVID-19 related stressors in predicting adverse psychological trajectories using elastic net regression. Results showed that CM was longitudinally associated with all adverse psychosocial outcome. COVID-19 perceived stressors, rumination, and insecure attachment mediated this relationship and full mediation was observed for the outcomes anxiety, stress and psychological well-being. COVID-19-related concerns about the future was most strongly and consistently associated with adverse psychosocial functioning. These findings provide preliminary evidence that COVID-19 perceived stressors, in particular concerns about the future, may be a key mechanism underlying the development of adverse psychosocial outcomes in individuals with a CM history. Thus, COVID-19 perceived stressors may require a higher priority for prevention and treatment efforts in vulnerable groups. Our results warrant replication in more representative cross-cultural samples.

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.

[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.

Altered immediate behavioral response to partial social exclusion: A cross-diagnostic study in patients with borderline personality disorder and persistent depressive disorder

Borderline personality disorder (BPD) and persistent depressive disorder (PDD) are related to interpersonal dysfunction which might become particularly apparent in situations of social exclusion (SE). While emotional responses to SE have been widely explored, behavioral data in clinical samples are lacking. In this cross-diagnostic study, we applied a variant of the Cyberball paradigm to investigate the dynamic behavioral response to partial SE in BPD and PDD. BPD patients (n = 36), PDD patients (n = 34) and age and gender matched healthy controls (HC) (total n = 70) played experimental (i.e. partial SE Cyberball) and control (i.e. inclusion only) conditions in randomized order. While all groups tended to increase ball tosses towards the excluder in response to SE, this behavioral turn was significantly lower in PDD (p = .03, d = -.30) and trendwise in BPD patients (p = .06, d = -.28). Thus, an altered immediate response to partial SE was observed in BPD and PDD, in addition to the emotional reactions. This study supports the hypothesis of a behavioral coping with SE in BPD and PDD that might be problematic in the long run and provides an experimental paradigm for future research on interpersonal dysfunction.

Maternal attachment representation, the risk of increased depressive symptoms and the influence on children's mental health during the SARS-CoV-2-pandemic

The social distancing measures and the related closure of education institutions have confronted young families, in particular, with various challenges. Additional risk factors such as an insecure or even unresolved maternal attachment representation may affect mental health of mothers and their children in times of increased stress such as during the ongoing pandemic. We aimed to analyze the interplay between maternal attachment representation and mother's and children's mental health before and during the SARS-CoV-2-pandemic. 91 mothers completed a "SARS-CoV-2 pandemic survey" examining the pandemic-related stress of their families including their own depressive symptomology and their children's mental health. Our mediation analysis demonstrates that the mothers' depressive symptomology significantly and fully mediated the relationship between maternal attachment representations and children's mental health during the pandemic. In contrast, the indirect effect of the maternal attachment representation on children's mental health before the pandemic through the depressive symptoms experienced by the mothers before the pandemic did not reach significance alongside the total and direct effect. The quality of the maternal attachment representation, promoted by childhood maltreatment, seems to be one relevant risk factor for the mothers' and children's mental health during a stressful time like a pandemic. The risk for mothers to develop depressive symptoms in times of a pandemic is significantly influenced by their current representation of previous attachment experiences. In addition, the mental well-being of mothers showed a considerable influence on the children's mental health during a pandemic. The results underline the necessity to consider unique needs of family members and to offer specific support in the current crisis focusing on attachment issues.

Differential effect of childhood emotional abuse on present social support in borderline disorder and depression: a cross-sectional study

BACKGROUND

Perceived social support (PSS) is a crucial factor in physical and mental health. Previous studies found a negative association between childhood maltreatment (CM) and current PSS.

OBJECTIVE

In this paper, we investigate whether psychopathology moderates this association in a sample of patients with Depressive Disorder (DD) and Borderline Personality Disorder (BPD).

METHOD

Sixty-nine patients with DD and 110 patients with BPD were recruited to inpatient/day clinic treatment programmes for either DD or BPD. All participants completed the Childhood Trauma Questionnaire (CTQ) and the Social Support Questionnaire (F-SozU). Our hypothesis was tested with a moderator analysis in a multiple linear regression model.

RESULTS

We found a significant interaction between diagnosis and CM for the CTQ total score and the emotional abuse subscale. Post hoc analyses revealed a significant negative correlation between CM and PSS only for patients suffering from BPD and not for patients with DD.

CONCLUSION

Our results suggest that the negative association between CM and PSS might be more pronounced in certain patient groups, particularly patients with BPD.

Improving emotion regulation of social exclusion in depression-prone individuals: a tDCS study targeting right VLPFC

BACKGROUND

Growing evidence has indicated that right ventrolateral prefrontal cortex (RVLPFC) is critical in down-regulating emotional responses to social exclusion, and that depression is accompanied by social emotional dysregulation associated with reduced lateral prefrontal engagement. This study used anodal transcranial direct current stimulation (tDCS) to examine whether stimulating RVLPFC could improve emotional down-regulation of social exclusion in individuals with high depressive mood (DM).

METHODS

A total of 96 high and 94 low DM individuals received active or sham tDCS while viewing social exclusion or individual negative pictures under no-reappraisal (passive viewing) and reappraisal conditions. Participants rate their negative emotional experience following the presentation of each image. Pupil diameter and visual fixation duration were also recorded during the task.

RESULTS

It was found that tDCS-activated RVLPFC induced a stronger regulation effect on social exclusion than individual negative emotions. The effect of tDCS on regulation of social exclusion was more pronounced in low v. high DM individuals.

CONCLUSIONS

These findings demonstrate the specific role of RVLPFC on social emotion regulation, which has implications for refining target areas for the treatment of social emotion dysregulation in depression. However the findings do not suggest that high DM individuals benefit from a single-tDCS session on the emotion regulation of social exclusion. Thus we suggest to use multiple tDCS sessions or transcranial magnetic stimulation to further explore the therapeutic proposal in the future.

The vicious circle of social exclusion and psychopathology: a systematic review of experimental ostracism research in psychiatric disorders

Social exclusion (ostracism) is a major psychosocial factor contributing to the development and persistence of psychiatric disorders and is also related to their social stigma. However, its specific role in different disorders is not evident, and comprehensive social psychology research on ostracism has rather focused on healthy individuals and less on psychiatric patients. Here, we systematically review experimental studies investigating psychological and physiological reactions to ostracism in different responses of psychiatric disorders. Moreover, we propose a theoretical model of the interplay between psychiatric symptoms and ostracism. A systematic MEDLINE and PsycINFO search was conducted including 52 relevant studies in various disorders (some of which evaluated more than one disorder): borderline personality disorder (21 studies); major depressive disorder (11 studies); anxiety (7 studies); autism spectrum disorder (6 studies); schizophrenia (6 studies); substance use disorders (4 studies); and eating disorders (2 studies). Psychological and physiological effects of ostracism were assessed with various experimental paradigms: e.g., virtual real-time interactions (Cyberball), social feedback and imagined scenarios. We critically review the main results of these studies and propose the overall concept of a vicious cycle where psychiatric symptoms increase the chance of being ostracized, and ostracism consolidates or even aggravates psychopathology. However, the specificity and stability of reactions to ostracism, their neurobiological underpinnings, determinants, and moderators (e.g., attachment style, childhood trauma, and rejection sensitivity) remain elusive.

Personality Structure and Attachment in Bipolar Disorder

BACKGROUND

An impairment of self and interpersonal functioning has an impact on coping strategies, regulation of affect and stress. Little is known so far about the impairment of personality functioning in patients with bipolar disorder (BD). The aim of this study is to assess the effects of personality structure and attachment in BD patients on the symptom burden.

METHODS

Forty-six patients with the diagnosis of BD were assessed by the 12-item Operationalized Psychodynamic Diagnosis Structure Questionnaire (OPD-SQS), the short version of Experience in Close Relationship-revised (ECR-R-D), and the Brief Symptom Inventory-18 (BSI 18) to determine the level of personality functioning, attachment patterns, and symptom load.

RESULTS

We observed positive correlations between personality difficulties, insecure attachment, and symptom load in patients with BD. A low level of structural integration and an insecure attachment style in patients with BD were accompanied by a significantly higher symptom load (r = 0.66, p ≤ 0.01). Interestingly, there were no significant differences in the structural integration (T(1.44) = -0.93, p = 0.357) and in the attachment style attachment related avoidance: (T(1,44) = 1.50, p = 0.140); attachment related anxiety (T(1,44) = -0.781, p = 0.439) of study participants with BD when compared to the normative value of the general population.

LIMITATIONS

Our limitations are the small sample size of our group and the lack of a control group.

CONCLUSION

In general, our results suggest that there is a link between personality structure and affective dynamics including depressive, anxiety, and somatization symptoms in BD. These findings underline the increasing importance of assessing personality structure and attachment for diagnosis and treatment planning of BD.

Child maltreatment and depression: A meta-analysis of studies using the Childhood Trauma Questionnaire

BACKGROUND

Researchers have documented that child maltreatment is associated with adverse long-term consequences for mental health, including increased risk for depression. Attempts to conduct meta-analyses of the association between different forms of child maltreatment and depressive symptomatology in adulthood, however, have been limited by the wide range of definitions of child maltreatment in the literature.

OBJECTIVE

We sought to meta-analyze a single, widely-used dimensional measure of child maltreatment, the Childhood Trauma Questionnaire, with respect to depression diagnosis and symptom scores.

PARTICIPANTS AND SETTING

192 unique samples consisting of 68,830 individuals.

METHODS

We explored the association between total scores and scores from specific forms of child maltreatment (i.e., emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect) and depression using a random-effects meta-analysis.

RESULTS

We found that higher child maltreatment scores were associated with a diagnosis of depression (g = 1.07; 95 % CI, 0.95-1.19) and with higher depression symptom scores (Z = .35; 95 % CI, .32-.38). Moreover, although each type of child maltreatment was positively associated with depression diagnosis and scores, there was variability in the size of the effects, with emotional abuse and emotional neglect demonstrating the strongest associations.

CONCLUSIONS

These analyses provide important evidence of the link between child maltreatment and depression, and highlight the particularly larger association with emotional maltreatment in childhood.

Response to ostracism in patients with chronic depression, episodic depression and borderline personality disorder a study using Cyberball

BACKGROUND

Social exclusion (ostracism) can lead to interactional frustration and may play an important role as trigger and symptom amplifier in affective disorders. To investigate immediate emotional and behavioral reactions as well as coping, social exclusion can be mimicked in experimental situations, e.g. in the Cyberball paradigm, a virtual ball tossing game which is well established in social psychology. The present cross-diagnostic study compares the responses to social exclusion in patients with chronic depression (CD), episodic depression (ED) and borderline personality disorder (BPD) in comparison to a healthy control group.

METHODS

After baseline characterization, 120 participants (29 patients with CD, 20 with ED, 28 with BPD and 43 healthy controls) played Cyberball with two virtual players and complete exclusion after three times receiving the ball. Thereafter, standard questionnaires were applied for measuring needs, threats, inner tension, emotions and behavioral intentions.

RESULTS

Patients with CD showed a higher intensity of ostracism and aversive impact, as well as the wish to escape the situation (behavioral intention) compared to ED. In most categories, CD and ED had scores between BPD and healthy controls (with this sequence) and with BPD patients showing the largest difference to healthy controls.

LIMITATIONS

The assessment did neither include objective behavioral measures (which is a general limitation in the majority of studies using Cyberball) nor any biological variables. The sample sizes of the diagnostic subgroups were moderate.

CONCLUSIONS

These findings support the hypothesis that social exclusion situations lead to a more aversive emotional and behavioral reaction in CD compared to ED. Psychological and biological underpinnings of these reactions should be addressed in future transdiagnostic studies. Moreover, psychotherapy in CD should focus on specific needs of CD patients for developing a functional coping in threatening interpersonal situations.

Social Support Versus Emotion Regulation: Mediators of Attachment and Psychological Problems After Social Exclusion

Introduction: Secure parental attachment improves the perception of available social support and the socialization of emotion regulation strategies. Research has suggested that both perceived social support and emotion regulation help individuals reappraise stressful situations as less stressful. Individuals under stress are at an increased risk for psychological problems.

Method: The current study examined whether social support, emotion regulation, and psychological inflexibility mediated the relation between parental attachment and psychological problems after a social exclusion task.

Results: Results indicated that secure parental attachment was associated with an increased ability to up-regulate emotions and with an increase in the perception of available social support. Secure attachment to either parent was indirectly associated with psychological problems reported after social exclusion.

Discussion: Indirect effects were found only for pathways from attachment through emotion regulation strategies, which suggests that emotion regulation may be a driving factor between attachment to parental figures and stress induced psychological problems. Further results, limitations, and implications were discussed.

Differences between chronic and nonchronic depression: Systematic review and implications for treatment

BACKGROUND

There is still uncertainty if and to what extent chronic depression (CD) presents with specific features especially in contrast to the nonchronic course of major depressive disorder (non-CD). This systematic review aims to summarize the existing literature regarding sociodemographic factors, psychopathology, and course of disease in patients with CD in comparison to patients with non-CD.

METHODS

A structured database search (MEDLINE, PsycINFO, Web of Science, CENTRAL) was performed. All studies comparing CD with non-CD patients were included. Twenty-eight studies, including cohort studies, cross-sectional studies, and observational studies, were identified in which both subgroups were diagnosed according to DSM-IV or DSM-5, respectively. Primary outcome were group comparisons focused on sociodemographic factors, childhood adversity, onset of the disorder, comorbidities, severity and course of the depressive symptoms, and specific psychopathology.

RESULTS

Patients with CD had an earlier onset of depressive symptoms, higher rates of psychiatric comorbidities, and a complicated treatment course (e.g., higher rates of suicidality) compared to non-CD. We also found some evidence for specific features in the psychopathology of CD patients (submissive and hostile interpersonal styles) in contrast to non-CD patients. Results were inconsistent with regard to childhood maltreatment. No differences were found regarding the severity of depressive symptoms and most sociodemographic factors.

CONCLUSION

Despite some inconsistencies, the results of this review verified important differences between CD and non-CD. However, future research is needed to characterize especially the specific psychopathology of CD in comparison to non-CD patients to develop more tailored treatment strategies.

[Attachment Based Short Intervention During Inpatient Treatment of Adolescents]

Attachment Based Short Intervention During Inpatient Treatment of Adolescents In clinical attachment research the established and economic Adult Attachment Projective Picture System (AAP) has been increasingly used in the past few years to assess the attachment representations in adults and recent studies demonstrated sufficient validity for assessing attachment representations in adolescents. Apart from coding attachment classifications, the AAP provides useful and clinically valid information concerning attachment related defences, aspects of capacity to act and synchrony in relationships and emotion regulation strategies with respect to attachment related traumatic experiences. These valuable aspects with respect to individual resources led to the conceptualization to implement the AAP in the therapeutic setting as a feedback tool. In this pilot case we report on an adolescent patient in an inpatient setting. The therapist received an individualized feedback on the patients' AAP to focus on specific attachment related themes used as a short intervention respective an add-on treatment. This paper presents the first results of this new approach by demonstrating the potential therapeutic effects and process of therapy.

Insecure attachment style and cumulative traumatic life events in patients with somatoform pain disorder: A cross-sectional study

OBJECTIVE

Current models assume somatoform pain disorder (SPD) to be the result of a complex interaction between bio- and psychosocial factors, but the etiology is still not well understood. This study aimed to investigate the distribution of attachment style and the frequency of traumatic life events, especially childhood adversities, in patients with SPD compared to healthy controls.

METHODS

We compared 65 patients with SPD (confirmed by Structured Clinical Interview, SCID-I) to 65 age- and gender-matched healthy controls. The following questionnaires were employed: Relationship Scale Questionnaire (RSQ), Essen Trauma Inventory (ETI), Childhood Trauma Questionnaire (CTQ) and Patient Health Questionnaire (PHQ-15). A logistic regression analysis was used to identify the association between SPD and psychological factors.

RESULTS

Insecure attachment was significantly more prevalent (60%) in patients with SPD compared to healthy subjects (14%; p<0.001). Overall, 70.4% of patients with SPD reported three or more traumatic events in their life, compared with healthy subjects who reported predominantly one (40%). Patients with SPD scored significantly higher in all CTQ subscales compared to the healthy controls. The factor most strongly related with SPD was the insecure attachment style (OR=11.20, 95% CI: 1.32-94.86). Other significant predictive factors were depression (OR=3.35, 95% CI: 1.84-6.11) and number of traumatic events (OR=2.04, 95% CI: 1.06-3.92). Insecure attachment, depression symptoms and the number of traumatic events explained 86.2% of the variance.

CONCLUSIONS

The high predictive value of insecure attachment style and cumulative traumatic events emphasize their importance as risk factors of SPD.