Attachment disorders diagnosed by community practitioners: a replication and extension.

BACKGROUND: While considered a rare diagnosis, reactive attachment disorder (RAD) is simultaneously the subject of considerable debate. A recent report suggested that RAD is overdiagnosed in community settings and that conduct problems may be used to make a diagnosis of RAD (Woolgar & Baldock, Child and Adolescent Mental Health, 20, 2015, 34-40). This study seeks to replicate and extend these findings. METHOD: Clinical assessment data from 100 consecutive admissions of maltreated foster and adopted children (ages 3-17) to a specialty treatment clinic in the United States were reviewed. Measures included semi-structured interviews of RAD and disinhibited social engagement disorder (DSED) symptoms and caregiver-report questionnaires of emotional problems, conduct problems, and the quality of the parent-child relationship. RESULTS: Of the 100 cases reviewed, 39 presented with a diagnostic history of RAD, DSED, or 'attachment disorder'. Of these cases, three were diagnosed in-clinic with DSED; no cases met diagnostic criteria for RAD according to DSM-5 criteria. However, analyses found that those diagnosed with RAD by community-based clinicians were significantly more likely to display conduct problems and to be adopted (as opposed to in foster care). CONCLUSIONS: These findings confirm those of Woolgar and Baldock (Child and Adolescent Mental Health, 20, 2015, 34-40). It appears that the diagnostic criteria of RAD are commonly being inaccurately applied in general community-based practice. Clarification of diagnostic criteria for RAD in recent revisions of diagnostic taxonomies, the accumulation of empirical data on RAD, and improved instrumentation are either poorly disseminated or inadequately implemented in community-based practice settings.

A prospective longitudinal study of Reactive Attachment Disorder following early institutional care: considering variable- and person-centered approaches.

Although the study of reactive attachment disorder (RAD) in early childhood has received considerable attention, there is emerging interest in RAD that presents in school age children and adolescents. We examined the course of RAD signs from early childhood to early adolescence using both variable-centered (linear mixed modeling) and person-centered (growth mixture modeling) approaches. One-hundred twenty-four children with a history of institutional care from the Bucharest Early Intervention Project, a randomized controlled trial of foster care as an alternative to institutional care, as well as 69 community comparison children were included in the study. While foster care was associated with steep reductions in RAD signs across development, person-centered approaches indicated that later age of placement into families and greater percent time in institutional care were each associated with prolonged elevated RAD signs. Findings suggest the course of RAD is variable but substantially influenced by early experiences.

Recognition of attachment difficulties and developmental trauma is the responsibility of all paediatricians.

This article provides an overview of attachment theory, developmental trauma and trauma-informed care for paediatricians. The impact of difficult or impoverished parent-child relationships on brain development and long-term health is now well known. Recent neuroscience research reveals the adverse neurological impacts of developmental trauma and supports the biological basis of attachment theory. There is also an increasing body of evidence that childhood adversity is common and impacts physical and mental health throughout the life-span. Comprehensive paediatric assessment should include an understanding of attachment difficulties and developmental trauma. Viewing children and their families through a 'trauma-informed lens' can provide critical insights into their clinical presentation and care needs. All paediatricians should be providing and practicing trauma-informed care.

Attachment avoidance, alexithymia, and gender: Examining their associations with distress disclosure tendencies and event-specific disclosure.

Distress disclosure has been linked with reduced psychological distress, increased wellbeing, and successful psychotherapeutic outcome. Because of the importance of distress disclosure, researchers have worked to develop and improve theoretical models of disclosure to facilitate counseling practices that reduce impediments to disclosure. Presently, we conducted a 2-part study to investigate distress disclosure's associations with attachment avoidance, gender, and alexithymia-3 constructs frequently linked with disclosure. In Part 1, we examined the extent to which attachment avoidance, alexithymia, and gender predicted general disclosure tendencies. In Part 2, we examined the extent to which attachment avoidance, alexithymia, and gender predicted event-specific disclosure. Participants were recruited from a crowdsourcing website (N = 178 in Part 1; N = 108 in Part 2). In Part 1, alexithymia partially mediated the association between attachment avoidance and disclosure tendencies, and the link between attachment avoidance and alexithymia was stronger for men than women. In Part 2, the association between distress intensity and event-specific disclosure was weaker for people with high levels of alexithymia. Implications for counseling theory and practice are discussed. (PsycINFO Database Record

Adult attachment as a predictor and moderator of psychotherapy outcome: A meta-analysis.

Bowlby's attachment theory describes characteristic patterns of relating to close others and has important implications for psychotherapy. Attachment patterns have been characterized as secure (healthy interdependence with others), anxious (overdependence on others), and avoidant (difficulty relying on others). We update a previous meta-analysis to determine the association of patient attachment with psychotherapy outcome. Meta-analysis of 36 studies (3,158 patients) suggested that patients with secure attachment pretreatment show better psychotherapy outcome than insecurely attached patients. Further, improvements in attachment security during therapy may coincide with better treatment outcome. Finally, preliminary moderator analyses suggest that those who experience low pretreatment attachment security may find better treatment outcome in therapy that incorporates a focus on interpersonal interactions and close relationships. The article closes with research limitations, diversity considerations, and therapeutic practices.

A case study illustrating the use of an attachment video-feedback intervention strategy.

Children from high-risk environments are more likely to experience problems in development. Many difficulties are linked to early experiences in the context of the emerging attachment relationship. Over the past 20 years, our group has collaborated with government agencies to develop and implement an attachment-based video-feedback intervention strategy (AVI) that targets parental sensitivity and attachment. This case study presents the manner in which a young mother and her 6-month-old son experienced AVI. The study shows how the absence of maternal sensitivity and responsiveness to infant signals, difficulties in helping the child regulate affect, and problems in autonomy support are addressed via eight semi-structured mentoring visits. Discussion focuses on how AVI may be a helpful addition to primary prevention programs.

Treating disorganized attachment in the Group Attachment-Based Intervention (GABI©): A case study.

This paper describes the treatment of a mother and child who demonstrated disorganized attachment behaviors in their interactions with one another. The mother, who was diagnosed with Borderline Personality Disorder, felt incapable of managing her aggressive toddler and his emotional needs. The dyad was referred for therapy due to concerns about his developmental progress, evident delays having been mainly attributed to the problems observed within the parent-child relationship. The primary intervention applied to working with the dyad was the Group Attachment-Based Intervention (GABI©), developed by Anne Murphy in collaboration with Miriam Steele and Howard Steele. The mother also received individual psychotherapy as a supplement to the dyadic and group work of GABI©. The process and outcome of this comprehensive approach to treating a vulnerable dyad is explored in this case study.

[Attachment Based Short Intervention During Inpatient Treatment of Adolescents]. / Bindungsbezogene Kurzintervention im Rahmen stationärer Behandlung bei Jugendlichen.

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.

Developing Emotion-Based Case Formulations: A Research-Informed Method.

OBJECTIVES: New research-informed methods for case conceptualization that cut across traditional therapy approaches are increasingly popular. This paper presents a trans-theoretical approach to case formulation based on the research observations of emotion. METHODS: The sequential model of emotional processing (Pascual-Leone & Greenberg, 2007) is a process research model that provides concrete markers for therapists to observe the emerging emotional development of their clients. We illustrate how this model can be used by clinicians to track change and provides a 'clinical map,' by which therapist may orient themselves in-session and plan treatment interventions. RESULTS: Emotional processing offers as a trans-theoretical framework for therapists who wish to conduct emotion-based case formulations. First, we present criteria for why this research model translates well into practice. Second, two contrasting case studies are presented to demonstrate the method. CONCLUSIONS: The model bridges research with practice by using client emotion as an axis of integration. Key Practitioner Message Process research on emotion can offer a template for therapists to make case formulations while using a range of treatment approaches. The sequential model of emotional processing provides a 'process map' of concrete markers for therapists to (1) observe the emerging emotional development of their clients, and (2) help therapists develop a treatment plan. Copyright © 2016 John Wiley & Sons, Ltd.

[Treatment of parent-adolescent conflicts with the therapy program for adolescents with disturbances of self-esteem, performance and relationships (SELBST) ­ concept and results of a pilot study]. / Behandlung von Eltern-Jugendlichen-Konflikten nach dem Therapieprogramm für Jugendliche mit Selbstwert-, Leistungs- und Beziehungsstörungen (SELBST) ­ Konzeption und Ergebnisse einer Pilotstudie.

Objective: Parent-adolescent conflicts often comprise the reasons for the referral of adolescents in treatment facilities. However, studies on the effects of behavioral interventions with this indication are rarely published, even in the international literature. In an explorative study, we assessed the efficacy and the acceptance of systemic-behavioral treatment modules of the treatment program for adolescents with disturbances of self-esteem, performance and relationships (SELBST). Method: Ten adolescents aged 12 to 18 years (mean age 14,7 years) and their parents with severe parent-adolescents conflicts according to clinical judgment and with increased parent and adolescent ratings of conflicts on the Conflict-Behavior-Questionnaire-Cologne were included in the study. Results: Analyses of pre to post changes showed a reduction in conflicts and/or an increase in conflict-solving skills as rated by the parents on various outcome measures. However, parents had problems attending the family sessions regularly and to implement therapeutic tasks in the daily family routine which may have limited the effects of the intervention. Conclusions: There is preliminary evidence that SELBST is a useful program for the treatment of parent-adolescent conflicts. To further increase the effectiveness of the program, knowledge from this trial has been considered in the development of the manual.

Integrative Treatment of Personality Disorder. Part I: Psychotherapy.

In this paper, we outline the concept of integrative therapy of borderline personality, also referred to as fragmented personality, which we consider to be the core psychopathology underlying all clinical subtypes of personality disorder. Hence, the terms borderline personality, borderline disorder, fragmented personality, and personality disorder are used interchangeably, as synonyms. Our integrative approach combines pharmacotherapy and psychotherapy, each specifically tailored to accomplish a positive feedback modulation of their respective effects. We argue that pharmacotherapy and psychotherapy of personality disorder complement each other. Pharmacological control of disruptive affects clears the stage, in some cases builds the stage, for the psychotherapeutic process to take place. In turn, psychotherapy promotes integration of personality fragments into more cohesive structures of self and identity, ultimately establishing self-regulation of mood and anxiety. We introduce our original method of psychotherapy, called reconstructive interpersonal therapy (RIT). The RIT integrates humanistic-existential and psychodynamic paradigms, and is thereby designed to accomplish a deep reconstruction of core psychopathology within the setting of high structure. We review and comment the current literature on the strategies, goals, therapy process, priorities, and phases of psychotherapy of borderline disorders, and describe in detail the fundamental principles of RIT.

[AIT (Adolescent Identity Treatment) - an Integrative Treatment Model for the Treatment of Personality Disorders]. / AIT (Adolescent Identity Treatment) ­ ein integratives Therapiekonzept zur Behandlung von Persönlichkeitsstörungen.

AIT (Adolescent Identity Treatment) - an Integrative Treatment Model for the Treatment of Personality Disorders Personality disorders are patterns of maladaptive personality traits that have an impact on the individual throughout the life span. Borderline Personality Disorder (BPD) is a very severe, but treatable mental disorder. Identity disturbance is seen as the central construct for detecting severe personality pathology - and, most notably, borderline personality disorder - in adults and adolescents. Crises in the development of identity usually resolve into a normal and consolidated identity with flexible and adaptive functioning whereas identity diffusion is viewed as a lack of integration of the concept of the self and significant others. It is seen as the basis for subsequent personality pathology, including that of borderline personality disorder. Although BPD has its onset in adolescence and emerging adulthood the diagnosis is often delayed. In most cases, specific treatment is only offered late in the course of the disorder and to relatively few individuals. Adolescent Identity Treatment (AIT) is a treatment model that focuses on identity pathology as the core characteristic of personality disorders. This model integrates specific techniques for the treatment of adolescent personality pathology on the background of object-relation theories and modified elements of Transference-Focused Psychotherapy. Moreover, psychoeducation, a behavior-oriented homeplan and intensive family work is part of AIT.

[Impact of attachment behavior on chronic and somatoform pain]. / Einfluss des Bindungsverhaltens auf chronischen und somatoformen Schmerz.

In addition to being a risk factor for the course of chronic pain, the personality characteristics of the individual attachment style are also predictors for the success of medical and psychosocial interventions and aspects of the physician-patient relationship. Insecurely attached patients seem to be less able to sustain the positive effects of pain therapy. These results are especially relevant as insecure attachment patterns are overrepresented among chronic pain patients. As a result the attachment style can be seen as a psychosocial vulnerability factor for the chronification of acute pain.

[Stress-induced hyperalgesia (SIH) as a consequence of emotional deprivation and psychosocial traumatization in childhood : Implications for the treatment of chronic pain]. / Stressinduzierte Hyperalgesie (SIH) als Folge von emotionaler Deprivation und psychischer Traumatisierung in der Kindheit : Konsequenzen für die Schmerztherapie.

It is now widely recognized that in many chronic pain syndromes the intensity and severity of individually perceived pain does not correlate consistently with the degree of peripheral nervous system tissue damage or with the intensity of primary afferent or spinal nociceptive neurone activity. In particular, stress and anxiety exert modulatory influences on pain depending on the nature, duration and intensity of the stressor and developmental influences on the maturation of the stress as well as the pain system. In some chronic pain syndromes, e. g. fibromyalgia, TMD or somatoform disorders, no nociceptive or neuropathic input is detectable. We summarise the studies investigating the neural substrates and neurobiological mechanisms of stress-induced hyperalgesia (SIH) in animals and humans. The review provides new perspectives and challenges for the current and future treatment of chronic pain.

[Attachment Representation and Emotion Regulation in Patients with Burnout Syndrome]. / Repräsentationen früher Bindungsbeziehungen und Emotionsregulation bei Patienten mit Burnout-Syndrom.

OBJECTIVE: Burnout describes a syndrome of exhaustion resulting from insufficient coping with work-related distress. We investigated if patients that are being clinically treated for burnout show insecure and unresolved attachment representation more often compared with healthy controls. METHODS: 50 out of 60 consecutive burnout patients participated in the study. Mental representation of attachment was measured by using the Adult Attachment Interview. Additionally, we administered the Self Report Questionnaire to Assess Emotional Experience and Emotion Regulation and several burnout specific questionnaires. A population sample was used as control group. RESULTS: Burnout patients were classified as insecurely attached significantly more often than controls. Unresolved attachment status concerning loss or trauma was found significantly more often within the burnout sample. Patients with insecure attachment representation reported a lower subjective significance of work. Patients with avoidant insecure attachment showed more depersonalisation. Patients with unresolved loss/trauma reported less social support. They showed more passive-negative emotion experience and emotion regulation characterized by externalization. CONCLUSION: The results of the study suggest that an insecure or unresolved attachment representation might constitute an intrapersonal risk factor for the development of burnout syndrome.

The Talking Cure of Avoidant Personality Disorder: Remission through Earned-Secure Attachment.

The concept of earned security is important and has significant implications for psychotherapy. Understanding how individuals with insecure attachment styles can develop secure attachment styles through reparative relationships, such as the therapeutic relationship, can assist psychotherapists in helping patients to overcome the effects of early negative life experiences. Personality disorders are commonly associated with negative experiences, such as abuse, neglect, and other empathic failures. These disorders are particularly difficult to treat because of their pervasive nature and the resultant defense mechanisms that often thwart psychotherapy. However, an understanding of the role that attachment can play in the etiology, symptomatology, and treatment of psychopathology can greatly enhance the therapeutic process. This case report describes the long-term psychodynamic psychotherapy of a woman with a history of childhood trauma, avoidant attachment style, and avoidant personality disorder. Through the therapeutic relationship, she developed a secure attachment, and her symptoms remitted, and her life drastically improved.

[Schema therapy with children and adolescents ­ a conceptual and evidence-based overview]. / Schematherapie bei Kindern und Jugendlichen ­ eine konzeptuelle und evidenzbasierte Übersicht.

The paper highlights the essential pillars of schema therapy as well as outlining the basic concepts of early maladaptive schemas, domains, emotional core needs, and the mode model. We present an overview of the important features of the schema therapy and look at the special schematic therapeutic relationship work, thereby focusing on emotional processes, needs-oriented biography work, age-appropriate psycho-education, and schema coaching for parents. Clinical recommendations are given based on the recent evidence.

Annual research review: Attachment disorders in early childhood--clinical presentation, causes, correlates, and treatment.

BACKGROUND: Though noted in the clinical literature for more than 50 years, attachment disorders have been studied systematically only recently. In part because of the ubiquity of attachments in humans, determining when aberrant behavior is best explained as an attachment disorder as opposed to insecure attachment has led to some confusion. In this selective review, we consider the literature on reactive attachment disorder and disinhibited social engagement disorder and describe an emerging consensus about a number of issues, while also noting some areas of controversy and others where we lack clear answers. We include a brief history of the classification of the disorders, as well as measurement issues. We describe their clinical presentation, causes and vulnerability factors, and clinical correlates, including the relation of disorders to secure and insecure attachment classifications. We also review what little is known and what more we need to learn about interventions. METHODS: We conducted a literature search using PubMed, PsycINFO, and Cochrane Library databases, using search terms 'reactive attachment disorder,' 'attachment disorder,' 'indiscriminate behavior,' 'indiscriminate friendliness,' 'indiscriminate socially disinhibited reactive attachment disorder,' 'disinhibited social engagement disorder,' and 'disinhibited social behavior.' We also contacted investigators who have published on these topics. FINDINGS: A growing literature has assessed behaviors in children who have experienced various types of adverse caregiving environments reflecting signs of putative attachment disorders, though fewer studies have investigated categorically defined attachment disorders. The evidence for two separate disorders is considerable, with reactive attachment disorder indicating children who lack attachments despite the developmental capacity to form them, and disinhibited social engagement disorder indicating children who lack developmentally appropriate reticence with unfamiliar adults and who violate socially sanctioned boundaries. CONCLUSIONS: Although many questions remain to be answered, especially regarding appropriate interventions, we know considerably more about attachment disorders than we did only a decade ago.

[Attachment and Adoption: Diagnostics, Psychopathology, and Therapy]. / Bindung und Adoption: Diagnostik, Psychopathologie und Therapie.

This presentation describes the development of attachment between adopted children and their adoptive parents with a focus on the particular issues seen in international adoptions. The questions of settling in, trauma in the country of origin, and the motivations of the adoptive parents will be discussed. Diagnosis and various psychopathological manifestations will be examined, as will outpatient and inpatient modes of therapy. The treatment of children of various ages will be covered along with the necessity for intensive counseling and psychotherapy for the adoptive parents. This will enable the parents to work through early trauma, which will give them and their adopted child the basis for developing healthy attachment patterns. This in turn will enable the child to mature and integrate into society. Possibilities of prevention are discussed. Many of the approaches discussed here regarding attachment and adoption may be applied to foster children and their foster parents.

Neurosciences and adult health behaviors: recent findings and implications for counseling psychology.

The current review comprehensively examines recent advances in 2 innovative areas of neuroscience research on healthy adults regarding neuropsychosocial interactions on human cognition and behavior, as well as implications for counseling psychologists conducting research and in practice. Advances in how oxytocin influences prosocial behavior and the mitigation of social stress, and the influence of environmentally mediated gene expressions on the development of attachment disorders are surveyed and discussed in terms of how counseling psychologists might best integrate recent neuroscience research into a framework for therapeutic intervention.