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Attachment: Attachment
Categories & Psychiatric
Disorders
19th Nov 2010
Dr Helen Brotherton
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
incompetent
Cummings & 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’-> ‘earnedsecure’ 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 common
Bipolar 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: 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
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 schizophreniaFamilial 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
 42months
.42***
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
 3-42months
.29***
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] (1537%), meeting criteria for multiple, incompatible
categories
 Violent men likely to be non-autonomous or CC