Exploring the Relationship Between Attachment and Pathological Personality Trait Domains in an Outpatient Psychiatric Sample.

ABSTRACT: The current study investigates the relationship between insecure attachment and pathological personality trait domains in a sample of psychiatric outpatients. Participants ( N = 150) completed measures for attachment and personality. Bivariate correlations and multiple regression analyses investigated the extent to which insecure attachment and personality pathology were associated. Insecure attachment positively correlated with overall personality pathology, with attachment anxiety having a stronger correlation than attachment avoidance. Distinct relationships emerged between attachment anxiety and negative affectivity and attachment avoidance and detachment. Insecure attachment and male sex predicted overall personality pathology, but only attachment anxiety predicted all five trait domains. Insecure attachment might be a risk factor for pathological personality traits. Assessing attachment in clinical contexts and offering attachment-based interventions could benefit interpersonal outcomes.

Childhood trauma as a mediator between attachment and recidivism risk: A study of Canadian offenders with mental disorders.

The current study aimed to explore the relationships between attachment and childhood trauma on recidivism risk in a sample of Canadian offenders with mental disorder (OMDs). N = 56 OMDs completed the Adverse Childhood Experiences (ACE) questionnaire, a measure of adult attachment (Experiences in Close Relationships Scale), and interview to determine recidivism risk (Level of Service/Case Management Inventory; LS/CMI). The variables of interest had small to moderate correlations. Multivariable regression analysis found that ACE scores but not attachment insecurity were associated with LS/CMI scores. Mediation analyses demonstrated that ACE scores fully mediated the association between attachment anxiety and attachment avoidance and recidivism risk. Results demonstrate that as exposure to diverse ACEs increased so did the risk to recidivate and this exposure mediated the relationship between attachment insecurity and recidivism risk. This study highlights the necessity of addressing both attachment insecurity and the experience of ACE when providing psychiatric services to OMDs.

Exploring the Impact of Religion and Spirituality on Mental Health and Coping in a Group of Canadian Psychiatric Outpatients.

Research has shown that religious/spiritual (R/S) beliefs can impact mental health. In addition, individual attachment impacts R/S views and mental health. Still, clinical studies are lacking. This study explores the presence of R/S beliefs and attachment insecurity in psychiatric outpatients and the implication for mental health. Ninety psychiatric outpatients reported their R/S beliefs and were categorized into two groups: religious/spiritual (+R/S) or nonreligious/spiritual (-R/S). The groups were compared on attachment, psychiatric symptoms, religious coping, and life satisfaction. Multivariate linear regression was also performed. The +R/S group had significantly higher religious coping and lower attachment insecurity, depression severity, and social anxiety. Attachment insecurity was associated with negative religious coping. Higher attachment avoidance was associated with lower life satisfaction and higher social anxiety. Many patients in psychiatric care hold R/S views and use religious coping. Their R/S beliefs and attachment characteristics might influence each other and impact their mental illness.

The Relationship between Adult Attachment and Mental Health Care Utilization: A Systematic Review.

OBJECTIVE: Several studies have shown a relationship between individual attachment and various aspects of treatment utilization in individuals with medical problems as well as mental health disorders. This review systematically evaluates existing literature targeting the relationship between attachment and all aspects of treatment utilization, such as engagement, participation, and completion, in adults with mental health problems. METHOD: A computerized search of PsycINFO, Medline, Embase, PubMed, and Healthstar and a manual search were employed. Of 5733 titles, 105 abstracts were selected. Of these, 18 studies met full inclusion criteria. The quality of studies was evaluated and scored according to 9 characteristics. RESULTS: Most studies supported an association between attachment and treatment engagement and participation. In general, attachment anxiety was associated with higher engagement and participation in services while attachment avoidance was associated with less. Data regarding attachment dimensions and treatment completion were less conclusive. CONCLUSIONS: The review suggests a clear relationship between attachment and stages of treatment engagement and participation in a variety of psychiatric populations and treatments. The 2 attachment dimensions appear to have opposite effects, with possible risks for either treatment over- or underutilization. Clinical implications are discussed.

Physicians' mental health and coping during the COVID-19 pandemic: One year exploration.

Numerous cross-sectional studies have examined physicians' health and coping during the COVID-19 pandemic, while longitudinal studies are lacking. This study explores the progression over one year of physicians' physical and mental health symptoms, their strategies used to cope and discusses coping strategies in relation to physical and mental health symptoms. Two surveys, one year apart, exploring physicians' physical, mental health symptoms and employed coping strategies were sent to all physicians practicing in the province of Saskatchewan, Canada. A total of 117 physicians participated in Round I (RI) (November 2020-January 2021) and 158 participated in Round II (RII) (October 2021-February 2022). Physicians' physical and mental health symptoms remained high, irrespective of their specialty or COVID-19 exposure. COVID-related Post-Traumatic Stress Disorder increased by five times at RII (p = 0.02). In RI anxiety was most prevalent in middle-aged females. In RII depression was most prevalent in physicians with no children. Most coping was adaptive (90%) and included Behavioural, Relational, Cognitive, Spiritual, and Interventional strategies. After one-year, Spiritual coping decreased, while Interventional coping increased by eight times (p = 0.01). Despite efforts to employ adaptive coping, physicians' rates of psychological and physical health difficulties remained high or worsened over one year, offering insight into the protracted health care crisis, and the need for solutions. Our observation of physicians' needs for additional supports, camaraderie and appreciation as well as the shift in coping strategies as the pandemic progressed, offer targets for interventions meant to promote recovery.

Doctors' Professional and Personal Reflections: A Qualitative Exploration of Physicians' Views and Coping during the COVID-19 Pandemic.

Numerous studies have examined the risks for anxiety and depression experienced by physicians during the COVID-19 pandemic. Still, qualitative studies investigating physicians' views, and their discovered strengths, are lacking. Our research fills this gap by exploring professional and personal reflections developed by physicians from various specialties during the pandemic. Semi-structured interviews were conducted with physicians practicing in the province of Saskatchewan, Canada, during November 2020-July 2021. Thematic analysis identified core themes and subthemes. Seventeen physicians, including nine males and eight females, from eleven specialties completed the interviews. The pandemic brought to the forefront life's temporality and a new appreciation for life, work, and each other. Most physicians found strength in values, such as gratitude, solidarity, and faith in human potential, to anchor them professionally and personally. A new need for personal fulfilment and hybrid care emerged. Negative feelings of anger, fear, uncertainty, and frustration were due to overwhelming pressures, while feelings of injustice and betrayal were caused by human or system failures. The physicians' appreciation for life and family and their faith in humanity and science were the primary coping strategies used to build adaptation and overcome negative emotions. These reflections are summarized, and implications for prevention and resilience are discussed.

The Relationship Between Attachment and Self-Injurious Behaviors in the Child and Adolescent Population: A Systematic Review of the Literature.

Adolescents have high rates of self-injurious behavior (SIB), with suicide being the second leading cause of death. A consistent relationship between individual attachment and SIB was previously found in adult population; however, no such review has been undertaken for the child and adolescent population. A systematic search of PubMED, OVID, and PsychINFO up to March 31, 2020 was performed. Twenty-two articles met the inclusion criteria. Of the 22 articles, 21 found a positive association between attachment insecurity and SIB. Our results show a consistent relationship between attachment insecurity and SIB in children and adolescents, complementing the results found in the adult literature. These findings make a case for preventive strategies aimed at reducing self-injurious behaviors in youth by targeting attachment security.

Alexithymia is a mediating factor in the relationship between adult attachment and severity of depression and social anxiety.

BACKGROUND: Major depressive disorder (MDD) and social anxiety disorder (SAD) are commonly occurring conditions, either alone or together (MDD-SAD). Recent research linked insecure attachment and alexithymia to MDD and/or SAD, indicating that the way affected individuals relate interpersonally and their ability to identify and communicate emotions are pertinent issues. The current study investigated the mediating role of alexithymia in the relationship between insecure attachment and severity of MDD and SAD symptoms. METHOD: Using the SCID-I, participants (N=159) were identified as MDD-only (n=43), MDD-SAD (n=56), or a healthy control (n=60). Participants completed measures of adult attachment, depression, social anxiety and alexithymia (defined as difficulty identifying and describing feelings). A two-step mediation analysis approach recommended by Shrout and Bolger determined if alexithymia mediates the relationship between attachment-depression and attachment-social anxiety. RESULTS: While alexithymia was high in MDD-only and MDD-SAD groups, individuals with MDD-SAD had significantly greater difficulty describing feelings. Alexithymia was a full mediator between attachment avoidance and depression, but only a partial mediator between attachment anxiety and depression. Meanwhile, alexithymia was a partial mediator for both attachment dimensions and social anxiety. LIMITATIONS: Causal inferences regarding insecure attachment, alexithymia, and MDD and SAD cannot be assumed given the cross-sectional data. The 'externally oriented thinking' component in alexithymia was also excluded from analyses due to low reliability. CONCLUSION: The results suggest emotional awareness and expression play a role in the illness severity for MDD and SAD-particularly in those with high attachment avoidance, offering a possible target for treatment and prevention strategies.

Attachment impacts cortisol awakening response in chronically depressed individuals.

BACKGROUND: Early life experiences shape individual attachment, creating a template for regulating emotions in interpersonal situations, likely to persist across the lifespan. Research has shown that individual attachment creates vulnerability for depression, and also impacts the Hypothalamic-Pituitary-Adrenal (HPA) axis. Still, the relationship between attachment and the HPA axis in depressed individuals is unclear. Cortisol awakening response (CAR) has been recently investigated as a possibly useful physiological marker related to attachment insecurity and depression risk. However, research exploring the relationship between the CAR and attachment in individuals with chronic depression in either the presence or the absence of comorbid anxiety is lacking. The purpose of the current study was to fill this gap, by comparing the CAR in individuals with chronic depression with/without comorbid anxieties and controls. In addition, we also wanted to explore the relationship between attachment and the CAR in this group and to explore their predictive role for later depression severity. METHODS: Individuals experiencing a current depressive episode at least six months in length (cMDD; n = 63) and healthy controls (HC; n = 57) were enrolled in the study (total n = 120). Participants completed a structured clinical diagnostic interview (SCID-I) as well as measures of depression severity (Beck Depression Inventory-II (BDI-II) and Hamilton Rating Scale for Depression) and attachment dimensions (Experiences in Close Relationships scale; ECR) at baseline. In addition, participants provided salivary samples at four time points (i.e. 0 (S1), 30, 45 and 60 min) following awakening on two consecutive days. S1 cortisol, the area under the curve with respect to ground (AUCg) and increase (AUCi) were calculated based on the average values across both days. The HC and cMDD groups were compared on all measures. The CAR for individuals with cMDD alone (n = 14) and individuals with cMDD with two or more comorbid anxiety disorders (cMDD ≥ 2Anx; n = 30) were also compared. A subset of participants (n = 59) agreed to return for follow up one year later. Participants returning for follow up repeated the BDI-II and ECR. No salivary samples were collected at follow-up. RESULTS: The cMDD group had significantly lower S1 cortisol and AUCg compared to the HC group (both p ≤ 0.02). cMDD and cMDD ≥ 2Anx groups did not differ in their CAR. Regression analyses revealed that depression severity and the attachment interaction term was associated with lower S1 and AUCg cortisol (p < 0.01). Greater attachment avoidance was positively associated with S1 cortisol (p = 0.02), while mean awakening time on sample days was negatively associated with S1 cortisol. We also found a significant interaction between the attachment dimensions such that at low levels of attachment anxiety, attachment avoidance had a positive relationship with S1 cortisol and AUCg. The opposite relationship existed when attachment anxiety was high. Higher baseline BDI-II score and higher baseline attachment anxiety were predictive of higher scores on the BDI-II one-year later (both p < 0.05). CONCLUSIONS: The current findings bring evidence that depression severity is associated with blunting of the CAR irrespective of the comorbid status with anxiety disorders. In addition, attachment avoidance may protect against the CAR blunting in individuals with low attachment anxiety. However, individuals with high attachment anxiety and avoidance might have additional CAR blunting. Attachment anxiety might be a good predictor of future depression severity.

The relationship between attachment, treatment compliance and treatment outcomes in patients with obstructive sleep apnea.

OBJECTIVE: Obstructive sleep apnea (OSA) is a common condition with numerous health and psychological consequences. While treatment with Continuous Positive Airway Pressure (CPAP) is highly effective, it seems to be impacted by interpersonal aspects of the patient. The current study explores the role of two major interpersonal descriptors (attachment and relationship satisfaction) on treatment initiation and compliance with CPAP. The benefit of CPAP treatment on sleep measures and psychological functioning is also examined. METHODS: Participants in stable relationships, diagnosed with OSA following an inpatient polysomnography test (N = 83), were recruited. Participants were appraised on their decision to initiate treatment and completed interpersonal measures (couples' satisfaction, attachment dimensions) as well as sleep measures and mental health measures. Participants were invited to repeat the measures after 3 months (N = 31 agreed). Associations between interpersonal measures and CPAP initiation and compliance as well as the impact of CPAP on sleep and all psychological measures was assessed. RESULTS: Individuals with high attachment anxiety pursued OSA treatment based on a mutual decision with the partner, while individuals with lower attachment anxiety made the decision themselves. Couples' satisfaction was positively associated with CPAP compliance over 3 months. CPAP compliance significantly improved sleep measures, mood and anxiety symptoms. CONCLUSION: The study brings evidence for a positive role of interpersonal factors in the initiation and compliance with OSA treatment as well as longitudinal benefits on sleep, mood and anxiety levels. The results can inform clinical approaches meant to increase treatment engagement and adherence in OSA patients through psychoeducation.

Self-Injurious Behaviors and Adult Attachment: A Review of the Literature.

Self-injurious behaviors (SIB) continue to afflict a significant segment of the clinical and general population, sometimes with fatal consequences. The development of SIB seems to share developmental pathways and mechanisms similar to attachment insecurity. To date, no reviews have explored their relationship. A search of publication databases PubMed and PsychInfo from 1969 through April 2018 was conducted and 17 papers met inclusion criteria. Of the 17 articles identified, 13 reported a positive relationship and 1 reported a negative relationship between attachment insecurity and SIB. Both attachment anxiety and avoidance seem to play a role in the risk for SIB, possibly through different mechanisms and likely with different impacts on the choice for either self-harm or suicide attempts.

A longitudinal exploration of the impact of social anxiety and individual attachment on depression severity.

BACKGROUND: Research suggests that insecure attachment and early onset of social anxiety disorder (SAD) create vulnerability for future depression. The current study explores the mediating role of social anxiety symptoms in the relationship between attachment and depression at baseline and one year later. The study also looks at the longitudinal impact of changes in attachment and social anxiety, on depression severity. METHODS: Participants (n = 162) completed structured clinical interviews and measures of depression, social anxiety, and adult attachment. A subsample of the participants (n = 77) returned for a follow-up one year later and repeated the measures. Mediation analysis and multivariate linear regression were performed to examine the relationships between depression, social anxiety, and attachment. RESULTS: Social anxiety was a full mediator of the relationship between attachment avoidance and depression severity at baseline but only a partial mediator at one-year follow-up. Social anxiety was a partial mediator of the relationship between attachment anxiety and depression severity at both baseline and follow-up. Lower baseline depression levels, improvement in social anxiety and improvement in attachment avoidance over the next year, predicted lower levels of depression at follow-up. LIMITATIONS: The study did not gather information regarding the treatments received between baseline and follow-up. CONCLUSIONS: Social anxiety plays a significant role in mediating the vulnerability towards severe depression in insecurely attached individuals. Treating social anxiety, particularly in individuals with avoidant attachment, might decrease the severity of future depression. In addition, interventions targeting attachment avoidance in youth might aid primary prevention strategies.

An exploration of adult attachment insecurity and psychiatric symptoms in individuals with obstructive sleep apnea.

OBJECTIVE: Obstructive sleep apnea (OSA) is a common sleep disorder, often associated with multiple medical comorbidities as well as psychological difficulties. Among the latter, relationship difficulties as well as mood and anxiety symptoms have been reported, without a clear understanding of the mechanism. In the current study we wanted to further explore these aspects, while comparing groups of OSA individuals with good vs poor sleep. The primary goal of the study was to examine the relationship between sleep and adult attachment and secondly to explore the relationship between sleep and couple satisfaction as well as symptoms of depression and anxiety. METHODS: Following diagnosis of OSA by overnight polysomnography, 102 participants completed several psychological measures (e.g. adult attachment, couple satisfaction, depression and anxiety symptoms) and sleep measures (sleep quality and daytime sleepiness). Variables of interest were compared between the OSA groups with either good/poor sleep quality or no/excessive daytime sleepiness. RESULTS: Adult attachment avoidance was higher in individuals with low sleep quality (mean difference = 0.33, p = .04, d = 0.46) while adult attachment anxiety was higher in individuals with high daytime sleepiness (mean difference = 0.46, p = .04, d = 0.43). Individuals with either poor sleep quality or excessive daytime sleepiness had greater severity of depression and anxiety (both p < .05). CONCLUSIONS: OSA patients with poor sleep quality and excessive daytime sleepiness have greater attachment insecurity and higher levels of depression and anxiety. A multidisciplinary approach including psychological interventions, should be considered in OSA cases with high levels of sleep disturbance.

The roles of attachment and resilience in perceived stress in medical students.

BACKGROUND: Medical students are susceptible to high levels of psychological stress, while being equipped with lower levels of resilience, especially females. Adult attachment is a known risk factor for a broad range of mental health difficulties and poor coping. The purpose of this study is to examine relationship attachment style, perceived stress, and resilience in medical students. METHODS: Data was collected via an online survey using self-report measures from University of Saskatchewan undergraduate medical students (n = 188). Attachment was assessed with the Relationship Questionnaire and Experiences in Close Relationships Scale. Resilience and stress were assessed with the Connor-Davidson Resilience Scale and Perceived Stress Scale, respectively. RESULTS: Approximately half of our sample endorsed secure attachment style (49.4%). Females reported significantly more attachment insecurity, higher attachment anxiety, higher perceived stress, and lower resilience compared to males, as expected. As predicted, attachment anxiety and avoidance were predictors of perceived stress. Mediation analyses supported the hypothesis that resilience acted as a partial mediator between attachment insecurity and perceived stress. CONCLUSION: These findings suggest attachment plays a role in perceived stress in medical students. In addition, the role of resiliency in protecting against this effect highlights potential areas for intervention to improve medical student well-being and provides a foundation for longitudinal follow-up.

Depression with or without comorbid social anxiety: Is attachment the culprit?

Major depressive disorder (MDD) frequently co-occurs with social anxiety disorder (SAD), and their comorbidity (MDD-SAD) increases clinical severity and functional impairment. Still, the specific psychological vulnerabilities of individuals with MDD-SAD are poorly understood. Individual attachment characteristics develop early in life through interactions with primary caregivers, and tend to persist throughout life. Early trauma can worsen attachment insecurity, increasing the risk for future anxiety and depression. The purpose of this study is to examine differences in individual attachment and history of trauma in depressed individuals with or without comorbid SAD and controls. One hundred sixty-two participants were categorized into three groups based on SCID-I interview: healthy controls (HC), individuals with current MDD without SAD (MDD), and individuals with current MDD comorbid with SAD (MDD-SAD). MDD-SAD group had significantly greater attachment anxiety and attachment avoidance compared to the MDD and HC groups. MDD-SAD group had greater clinician-rated depression severity and dysfunction compared to MDD group. In summary, the study further supports the clinical risks associated with MDD-SAD and suggests that insecure attachment might represent an associated vulnerability and a possible pathway which warrants further research and clinical attention.

Relationships between patients' attachment characteristics and views and use of psychiatric treatment.

This study explored the influence of attachment on psychiatric treatment by considering attitudes towards and the use of psychotropic medication and psychotherapy in patients with depressive and anxiety disorders. Adults referred to a psychiatrist completed self-report measures and participated in a diagnostic interview based on DSM-IV criteria. Those with depressive, anxiety or adjustment disorders were included (n = 124). Patients reported the types and dosage of current psychotropic medication as well as number of different psychiatrists and psychologists/counselors they had seen in the past 10 years. Multiple regression analyses were used to examine relationships between attachment anxiety and avoidance and the variables capturing treatment use and attitudes towards treatments. Attachment anxiety was positively associated with the number of current psychiatric medications and with both the number of psychiatrists and the number of psychologists/counselors seen. Attachment avoidance was negatively associated with the number of current psychotropic medications and beliefs about the efficacy of psychotherapy. The findings suggest that patients' attachment characteristics play a role in their views and choices regarding treatments. Developing treatments sensitive to the needs of insecurely attached individuals may lead to improved treatment outcomes.

When social anxiety and depression go together: A population study of comorbidity and associated consequences.

BACKGROUND: Despite several studies suggesting higher depression severity and dysfunction occurring in individuals with major depressive disorder (MDD) comorbid with social anxiety disorder (SAD), a clear understanding of the specific risks associated with this comorbidity is lacking. In this study we compared the disease characteristics and level of disability of individuals with MDD-SAD with other comorbidities between depression and anxiety. METHODS: Data from the Collaborative Psychiatric Epidemiology Surveys (CPES) (N=20,013) were used. Individuals were divided in four groups comparing MDD-SAD with MDD alone, as well as other comorbidities between MDD and one anxiety (MDD-1ANX) or more than two anxiety disorders (MDD≥2ANX), with respect to several clinical, demographic, and functional characteristics. RESULTS: MDD-SAD comorbidity in the general population occurred in younger people, particularly men, and seemed to have an earlier onset of MDD. Occupational and social dysfunction was similar between individuals with MDD-SAD and those with MDD-1ANX. However, individuals with MDD≥2ANX had significantly higher severity as measured by suicidality as well as substance abuse and social and occupational dysfunction. SAD was the most prevalent comorbid anxiety in this group. LIMITATIONS: The findings of this study were derived from the cross-sectional data. CONCLUSION: Our results suggest that the particular risks associated with MDD-SAD are the early onset and likelihood of additional anxiety, leading to higher severity and disability levels. Clinicians should increase the screening and treatment of SAD and other anxiety disorders in individuals with MDD given the higher associated health risk and functional impairment.

Relationships between adult attachment style ratings and sleep disturbances in a nationally representative sample.

OBJECTIVE: Recent research with small non-clinical and clinical samples suggests a positive association between attachment insecurity and sleep disturbances. The present study extends this line of research by exploring this relationship in a large sample of the U.S. population and by statistically adjusting for health conditions and psychiatric disorders as potential confounds. METHOD: The data used were from the National Comorbidity Survey Replication (N=5692). The main interview consisted of the Composite International Diagnostic Interview used to assess psychiatric diagnoses. Ratings of three adult attachment styles (viz., secure, avoidant, and anxious) were obtained along with self-reports of health conditions and four sleep disturbances (viz., difficulty initiating sleep, difficulty maintaining sleep, early morning awakening, and daytime sleepiness). RESULTS: Bivariate logistic regression analyses indicated that ratings of secure attachment were negatively associated with each sleep disturbance and ratings of insecure attachment were positively associated with each sleep disturbance. Multivariate logistic regression analyses were used to examine associations between the attachment ratings and sleep disturbances while statistically controlling for sociodemographic variables, the presence of a health condition, and psychiatric disorders (viz., depressive disorders, bipolar disorders, anxiety disorders, alcohol/substance disorders, and attention deficit disorder). With one exception, the insecure attachment ratings continued to be positively associated with sleep disturbances. CONCLUSION: The findings demonstrate that attachment insecurity is related to sleep disturbances independent of health conditions and concurrent psychiatric disorders. Research aimed at delineating the mechanisms responsible for these associations is warranted.