Disorganized attachment and emotion dysregulation as mediators of the association between sexual abuse and dissociation in preschoolers

Role of attachment style in the association between childhood adversities and non-suicidal self-injury among young adults: a multigroup structural equation study

Background

Non-suicidal self-injury (NSSI) is a significant health concern among adolescents and young adults, often resulting from adverse childhood experiences (ACEs). Dissociation, post-traumatic symptoms and attachment style may have a role in shaping such associations.

Aims

This study aims to provide a unified model of the impact of ACEs on NSSI, exploring complex post-traumatic stress disorder (cPTSD) symptoms and dissociation as potential mediators and the role of the predominant attachment style in affecting such associations.

Methods

1010 young individuals attending the last year of high school participated in this cross-sectional study. ACEs, cPTSD, dissociation and NSSI were evaluated using self-report questionnaires. We fitted a path model of NSSI, with ACEs as exogenous variables and cPTSD and dissociation as sequential mediators. Secure, fearful and preoccupied attachment styles were modelled as grouping variables.

Results

Our findings showed that dissociation mediated the impact of ACEs on NSSI in subjects with a fearful attachment style, as opposed to those with a preoccupied attachment for whom cPTSD symptoms mediated the ACEs-NSSI association.

Conclusions

Attachment styles moderate the relationship between ACEs and NSSI, with either dissociation or post-traumatic symptomatology mediating the impact of ACEs on NSSI, depending on the predominant attachment style. Our results highlight the importance of attachment as a pathway modifier in the relationships between different psychopathology dimensions, providing a useful framework to better conceptualise the ACEs-NSSI association.

Dissociation and misdiagnosis of schizophrenia in populations experiencing chronic discrimination and social defeat

As recently as the late 20th century, Schizophrenia, a category of mental illness with widely varying phenotypic symptoms, was believed by psychobiologists to be a genetically based disorder in which the environment played a limited etiological role. Yet a growing body of evidence indicates a strong correlation between schizophrenia and environmental factors. This theoretical paper explores the relationship between highly elevated rates of schizophrenia in some low-income minority communities worldwide and trauma-related dissociative symptoms that often mimic schizophrenia. Elevated rates of schizophrenia in racially and ethnically isolated, inner-city Black populations are well documented. This paper contains evidence proposing that this amplification in the rate of schizophrenia is mediated by childhood trauma, disorganized attachment, and social defeat. Further, evidence demonstrating how these three variables combine in early childhood to incubate dissociative disorders will also be conveyed. The misdiagnosis of dissociative disorders as schizophrenia is theorized to partially mediate the increased rate of schizophrenia in communities that experience high levels of racial/ethnic discrimination. It is argued that this misdiagnosis is often attributable to cultural misunderstanding and/or a lack of knowledge about dissociative disorders.

Why We Need a Developmentally Appropriate Trauma Diagnosis for Children: a 10-Year Update on Developmental Trauma Disorder

Developmental Trauma Disorder (DTD) was proposed almost two decades ago as a psychiatric diagnosis for children who have been traumatically victimized and whose attachment bonding with primary caregivers has been compromised. DTD was designed to complement and extend post-traumatic stress disorder (PTSD) by addressing forms of trauma-related biopsychosocial dysregulation not included in PTSD, many of which are attributed to other psychiatric disorders. In the past decade, evidence from clinician surveys and research field trial studies has provided evidence of DTD's validity and potential clinical utility. The growing evidence base for DTD is summarized and clinical rationales for the proposed DTD symptoms are described. DTD shows promise as a developmentally-attuned traumatic stress diagnosis for traumatized children.

A novel ego dissolution scale: A construct validation study

Ego dissolution (i.e., ego loss, ego disintegration, ego death, or self-loss) is a conscious state marked by a loss or diminution of one's sense of self and a lack of first-person experience. We developed a novel, valid, and internally consistent ego dissolution scale to both (a) assess trait-like aspects of ego dissolution, which have received scant attention to date, and (b) facilitate future research in a variety of contexts (e.g., personality, psychopathology, substance use/psychedelics, contemplative practices). We determined that the 10-item Ego Dissolution Scale (EDS; Cronbach's α = 0.80) and its identified subfactors of Ego-Loss (Cronbach's α = 0.84) and Unity (Cronbach's α = 0.75) were internally consistent, possessed strong convergent (e.g., depersonalization/derealization, mysticism, unusual experiences) and discriminant validity (e.g., neuroticism, social desirability). We found ego dissolution and dissociation to be empirically related yet discriminable on a statistical basis.

Disorganized attachment in emerging adulthood: Measurement comparisons and relations to childhood maltreatment and emotion dysregulation

There is an abundance of research examining disorganized attachment in childhood. However, few researchers have worked to advance the study of disorganized attachment in the context of emerging adult romantic relationships. As such, consistent and clear measurement of this attachment dimension is lacking. In the current study, emerging adult college students (N = 318) completed two previously designed self-report measures for assessing adult disorganized attachment in the context of romantic relationships. The two scales were compared in a factor analytic framework to create a single cohesive measure of romantic disorganized attachment, which captures the unique features of disorganized attachment, including fear, distrust and suspicion of attachment figures, as well as odd and disoriented behaviors. The result was a 15-item measure, which showed good reliability and factorial validity, and was moderately related to existing measures of attachment anxiety and avoidance. Additionally, the new measure demonstrated good test-retest reliability in a follow-up (n = 52). Finally, path analysis was used to provide evidence that disorganized attachment mediates the relation of childhood maltreatment to difficulties in emotion regulation, above what is captured by anxious and avoidant attachment. The current findings suggest the revised measure is a reliable self-report measure of disorganized adult romantic attachment to be used to further the study of disorganized attachment in emerging adulthood.

Effects of intellectual disability and attachment on hostile intent attribution bias

Understanding hostile intent attribution (HIA) seems important for prevention of problems in social adaptation. This study aimed to explore whether HIA in childhood is determined by both a cognitive factor (i.e. intellectual disability) and an affective factor (i.e. attachment representations). One hundred and eight 8- to 12-year-old children (54 with intellectual disability and 54 with typical development) passed the Attachment Story Completion Task and the Intention Attribution Test for Children. Results indicated that in ambiguous situations, attachment disorganization was associated with HIA, whereas intellectual disability was not. In nonintentional situations, both attachment hyperactivation and intellectual disability were linked with HIA. These results highlight the importance of helping children develop organized attachment representations and optimal activation of their attachment system to prevent social maladaptation.

Maternal History of Child Sexual Abuse and Maladaptive Outcomes in Sexually Abused Children: The Role of Maternal Mental Health

The effects of child sexual abuse (CSA) have been found to surpass generations as maternal history of CSA is associated with increased difficulties in sexually abused children. However, little is known about the mechanisms underlying this association. The present study aimed to test maternal mental health symptoms including psychological distress, post-traumatic stress disorder (PTSD) symptoms, and dissociation as mediators of the relationship between maternal CSA and children's internalizing, externalizing, and dissociation symptoms in a large sample of sexually abused children. A total of 997 sexually abused children aged 3-14 years old and their mothers were recruited at five specialized intervention centers offering services to sexually abused children and their families. The children were divided into two groups depending on their mothers' self-reported history of CSA. Mothers completed a series of questionnaires assessing their mental health and children's functioning. Maternal history of CSA was associated with increased maternal psychological distress, PTSD symptoms, and dissociation following children's disclosure of CSA. In turn, maternal psychological distress and maternal dissociation were associated with increased child internalizing, externalizing, and dissociation symptoms. Maternal PTSD symptoms were associated with child internalizing symptoms. Maternal mental health difficulties mediated the association between maternal CSA and sexually abused children's maladaptive outcomes. Clinicians should assess for possible history of CSA in mothers of sexually abused children and determine how best to support them to cope with the aftermaths of their child's disclosure and with their own traumatic past.

The role of attachment to the foster parent with regard to suicidal risk among adult survivors of childhood maltreatment

BACKGROUND

Childhood maltreatment is associated with an increased risk of insecure/disorganized attachment and in turn with suicidal risk (SR). Out-of-family placement is aimed at interrupting child exposure to further abuse and at providing the necessary security for proper development via the establishment of an alternative attachment relationship. However, the actual protective role of this type of care is not clear given the high rates of SR among institutionalized or foster children.

OBJECTIVE

The aim of this study was to examine whether 1) attachment to the biological parents mediates the association between abuse and SR and 2) attachment to a foster parent (whether from a foster home or an institution) moderates the effect of attachment to biological parents on SR.

PARTICIPANTS

The sample consisted of 77 adults (52 female; 25 male; mean age: 26.6 years) who received out-of-home care during childhood.

METHOD

The Childhood Trauma Questionnaire and the Mini International Neuropsychiatric Interview (for SR) were used. The Attachment Multiple Model Interview was also administered to assess attachment to each biological parent and to the foster parent.

RESULTS

Results show that attachment (security and disorganization) to the biological mother mediates the link between abuse and SR and that attachment to the foster parent moderates the link between attachment to the biological mother and SR.

CONCLUSIONS

Findings point to the importance of interventions aimed at supporting the establishment of a secure attachment relationship between children in care and their foster parents.

The role of multiple attachments in intergenerational transmission of child sexual abuse among male victims

BACKGROUND

According to Finkelhor (1984), difficulties child sexual abusers have in establishing adaptive adult relationships are a consequence of attachment problems with parents. Research shows that insecure attachment is associated with both the experience of child sexual abuse (CSA) as a victim and perpetration of CSA as an adult. Attachment may thus be a key factor in intergenerational transmission (IT) of CSA.

OBJECTIVE

The study aims to examine the direct, interactive, and mediated effects linking attachment in different relationships (mother, father, romantic partner) to IT of CSA among male victims.

PARTICIPANTS AND SETTING

Thirty-two abusing and 27 non-abusing male CSA survivors were recruited, respectively, in a prison and via networks of former foster children or CSA victims.

METHOD

All participants completed the Attachment Multiple Model Interview to assess attachment along four dimensions (security, deactivation, hyperactivation, and disorganization) in the relationship with mother, father, and partner.

RESULTS

Partial least square modeling suggests that the partner carries forward (mediates) the increased risk of committing sexual abuse associated with insecure/disorganized attachment with the father. A significant partner-mother interaction also suggests that the deleterious effects of attachment to the mother in terms of committing CSA are countered by more secure/organized attachment to the partner.

CONCLUSIONS

Findings highlight the pivotal role of the romantic partner in IT of CSA. Beyond early intervention, therapy in adulthood aimed at fostering adaptive ways of finding emotional security in the relationship with an adult could thus be encouraged.

The Molecular Genetics of Dissociative Symptomatology: A Transdiagnostic Literature Review

Dissociative disorders are a common and frequently undiagnosed group of psychiatric disorders, characterized by disruptions in the normal integration of awareness, personality, emotion and behavior. The available evidence suggests that these disorders arise from an interaction between genetic vulnerability and stress, particularly traumatic stress, but the attention paid to the underlying genetic diatheses has been sparse. In this paper, the existing literature on the molecular genetics of dissociative disorders, as well as of clinically significant dissociative symptoms not reaching the threshold of a disorder, is reviewed comprehensively across clinical and non-clinical samples. Association studies suggest a link between dissociative symptoms and genes related to serotonergic, dopaminergic and peptidergic transmission, neural plasticity and cortisol receptor sensitivity, particularly following exposure to childhood trauma. Genome-wide association studies have identified loci of interest related to second messenger signaling and synaptic integration. Though these findings are inconsistent, they suggest biologically plausible mechanisms through which traumatic stress can lead to pathological dissociation. However, methodological concerns related to phenotype definition, study power, and correction for the confounding factors limit the value of these findings, and they require replication and extension in studies with better design.

The Role of Implicit Memory in the Development and Recovery from Trauma-Related Disorders

Post-traumatic Stress Disorder is a chronic condition that occurs following a traumatic experience. Information processing models of PTSD focus on integrating situationally triggered sensory-emotional memories with consciously accessible autobiographical memories. Review of the nature of implicit memory supports the view that sensory-emotional memories are implicit in nature. Dissociation was also found to be associated with the development and severity of PTSD, as well as deficits in autobiographical memory. Moreover, disorganized attachment (DA) was associated with greater degrees of dissociation and PTSD, and like the defining neural activation in PTSD, was found to be associated with basal ganglia activity. In addition, subcortical neuroception of safety promotes a neurophysiological substrate supportive of social engagement and inhibition of fear-based responses. Furthermore, activation of representations of co-created imagined scenes of safety and secure attachment are associated with increases in this neurophysiological substrate. Repeated priming of secure attachment imagery was associated with modification of internal working models of DA along with reductions in dissociation and recovery from complex PTSD. In conclusion, it is posited that adequate recovery from extensive trauma experiences requires more than conscious elaboration of traumatic autobiographical memories and that the application of implicit nonconscious memory modification strategies will facilitate more optimal recovery.

Can developmental trauma disorder be distinguished from posttraumatic stress disorder? A symptom-level person-centred empirical approach

BACKGROUND

Developmental Trauma Disorder (DTD) is a proposed childhood psychiatric diagnosis for psychopathological and developmental sequela of victimization and attachment trauma extending beyond posttraumatic stress disorder (PTSD).

OBJECTIVE

To determine whether a sub-group of trauma-impacted children is characterized by symptoms of DTD that extend beyond, or co-occur with, the symptoms of PTSD.

METHOD

Person-centred Latent Class Analyses (LCA) were done with data from 507 children (ages 7-18 years, (M = 12.11, SD = 2/92); 49% female) referred to the study by mental health or paediatric clinicians.

RESULTS

A four class solution was optimal (LMR = 398.264, p < .001; Entropy = .93): (1) combined DTD + PTSD (n = 150); (2) predominant DTD (n = 156); (3) predominant PTSD (n = 54); (4) minimal symptoms (n = 147). Consistent with prior research, the DTD + PTSD class was most likely to have experienced traumatic emotional abuse and neglect (X² (3) = 16.916 and 28.016, respectively, p < .001), and had the most psychiatric comorbidity (F(3, 502) = 3.204, p < .05). Predominant DTD class members were most likely to meet criteria for Oppositional Defiant Disorder (ODD) (X²(3) = 84.66, p < .001).

CONCLUSION

Symptoms of DTD may occur with, or separately from, PTSD symptoms. Children with high DTD|+PTSD symptoms had extensive psychiatric comorbidity, while those with high DTD symptoms and minimal PTSD symptoms were highly likely to meet criteria for ODD. In clinical and research assessment and treatment of children with complex psychiatric comorbidity or disruptive behaviour problems, symptoms of DTD should be considered, both along with, and in the absence of, PTSD symptoms.

The moderation of maternal parenting on the association of trauma, dissociation, and psychosis in depressive inpatients

BACKGROUND

The effect of dissociation and parenting style on the relationship between psychological trauma and psychotic symptoms has not previously been investigated.

OBJECTIVE

The aim of this study was to develop a moderated mediation model to assess whether the association between psychological trauma and psychotic symptoms is mediated by dissociation and moderated by parental maltreatment.

METHODS

Inpatients with major depressive disorder (MDD) and bipolar depression (BP) were recruited. Self-reported and clinical rating scales were used to measure the level of dissociation, psychotic symptoms, history of psychological trauma and parental maltreatment. The PROCESS macro in SPSS was used to estimate path coefficients and adequacy of the moderated mediation model. High betrayal trauma (HBT), low betrayal trauma (LBT), paternal maltreatment, and maternal maltreatment were alternatively entered into the conceptual model to test the adequacy.

RESULTS

A total of 91 patients (59 with MDD and 32 with BP) were recruited, with a mean age of 40.59 ± 7.5 years. After testing with different variables, the moderated mediation model showed that the association between LBT and psychotic symptoms was mediated by dissociation and moderated by maternal maltreatment. A higher level of maternal maltreatment enhanced the effect of LBT on dissociation.

CONCLUSIONS

Healthcare workers should be aware of the risk of developing psychotic symptoms among depressive patients with a history of LBT and maternal maltreatment.

Attachment representations among school-age children with intellectual disability

BACKGROUND

Research data documenting a high risk of insecure and disorganized attachment among children with intellectual disability (ID) in infancy and early childhood raises the question of mutual influences between ID and attachment in later childhood.

AIMS

The objectives of the present study were to examine attachment among school-age children with ID and whether attachment varies according to level of intellectual functioning, adaptative functioning, and presence of a genetic syndrome (i.e. Down syndrome).

METHODS

Attachment among 54 children with ID aged 8-12 years (30 with Down Syndrome, 24 with non-specific ID) was assessed using the Attachment Story Completion Task, and compared with that of 108 typically developing children, 54 of the same chronological age and 54 of the same mental age.

OUTCOMES

Results show (1) less security among children with ID than among same-age controls (2) more disorganization among children with ID compared to the two control groups, (3) a link between attachment disorganization and level of adaptive functioning among children with ID and (4) no difference in attachment between children with DS and children with non-specific ID.

CONCLUSIONS

Children with ID remain vulnerable to disorganization during late childhood. More research is needed to understand the factors underlying disorganized attachment representations.

The intersection of intimate partner violence and childhood sexual abuse in mother-child dyads

BACKGROUND

Child sexual abuse (CSA) and intimate partner violence (IPV) have been associated with negative consequences for adult victims and their children including a risk of revictimization and intergenerational continuity.

OBJECTIVES

The aim of this study was to document correlates of intergenerational cumulative trauma profiles in mother-child dyads.

PARTICIPANTS AND SETTING

A sample of 997 sexually abused children (mean age = 7.61 years; 79.1% girls) and their mothers was recruited.

METHODS

Latent Class Analysis (LCA) was used to identify classes of cumulative trauma among dyads. Classes were compared on validated measures of psychological functioning for both members of the dyads.

RESULTS

Four distinct classes emerged: CSA Only (43.3%), Intergenerational CSA with Psychological IPV (14.2%), Physical and Psychological IPV with Low Child Exposure (24.0%) and Intergenerational Polyvictimization (18.5%). Comparisons generally revealed lower distress in CSA Only dyads, and higher levels of psychological difficulties in the two most victimized groups. However, the dose-response pattern was not as clear as expected, as the two most victimized groups did not differ in terms of psychological functioning.

CONCLUSIONS

This study shows that higher levels of intergenerational cumulative trauma are associated with increased psychological symptoms in mothers and more dissociation in their sexually abused children. Interventions should be adapted to the specific needs of families to prevent lasting intergenerational difficulties in trauma exposed individuals.

Complex PTSD and borderline personality disorder

BACKGROUND

This article builds on a previous review (Ford and Courtois, Borderline Personal Disord Emot Dysregul 1:9, 2014) which concluded that complex posttraumatic stress disorder (cPTSD) could not be conceptualized as a sub-type of either PTSD or BPD. Recent research is reviewed that extends and clarifies the still nascent understanding of the relationship between cPTSD and BPD.

MAIN BODY

The circumscribed formulation of adult cPTSD that has been developed, validated, and included in the 11th Edition of the International Classification of Diseases has spurred research aimed at differentiating cPTSD and BPD both descriptively and empirically. A newly validated Developmental Trauma Disorder (DTD) syndrome for children and adolescents provides a basis for systematic research on the developmental course and origins of adult cPTSD and BPD. This review summarizes recent empirical findings regarding BPD, PTSD, and cPTSD in terms of: (1) prevalence and comorbidity; (2) clinical phenomenology; (3) traumatic antecedents; (4) psychobiology; (5) emotion dysregulation; (6) dissociation; and (7) empirically supported approaches to clinical assessment and psychotherapeutic treatment.

CONCLUSION

The evidence suggests that PTSD, cPTSD, and BPD are potentially comorbid but distinct syndromes. A hypothesis is advanced to stimulate scientific research and clinical innovation defining and differentiating the disorders, positing that they may represent a continuum paralleling the classic conceptualization of the stress response, with dissociation potentially involved in each disorder.

Sexual violence victimization and suicide: Testing a coping-mental health framework

Sexual violence victimization is a prevalent public health concern. However, little research has investigated the factors linking sexual violence victimization to suicidal thoughts and behaviors (STBs). The current study tested the applicability of the psychological mediation framework, a coping-mental health model, for the prevention of STBs among victims of sexual youviolence. Furthermore, the current study explored whether sexual orientation moderated the progression from sexual violence victimization to STBs. Data were drawn from an online survey of victimization experiences and health (N = 2175). Bootstrap mediation tested whether the association of sexual violence victimization and STBs was mediated by emotion regulation strategies (cognitive reappraisal and expressive suppression) and psychopathology (anxiety, depression, and posttraumatic stress disorder). Multiple-groups analysis tested whether links within the mediation effects varied by sexual orientation. Bivariate findings showed that: (1) sexual minority persons were more likely to report sexual violence victimization and (2) cognitive reappraisal was more meaningfully associated with mental health among sexual minority persons. Sexual violence victimization was associated with STBs via a serial mediation through emotion regulation and psychopathology. The association between psychopathology and STBs was stronger among sexual minority compared with heterosexual respondents. Physical violence victimization was associated with STBs for heterosexual but not sexual minority persons in a follow-up model. Findings support an emotion regulation-mental health framework for the prevention of suicide among victims of sexual violence. Research and training implications are discussed.

Emotional Dysregulation in Children and Adolescents With Psychiatric Disorders. A Narrative Review

Background: Emotional dysregulation (ED) is a transdiagnostic construct defined as the inability to regulate the intensity and quality of emotions (such as, fear, anger, sadness), in order to generate an appropriate emotional response, to handle excitability, mood instability, and emotional overreactivity, and to come down to an emotional baseline. Because ED has not been defined as a clinical entity, and because ED plays a major role in child and adolescent psychopathology, we decided to summarize current knowledge on this topic based on a narrative review of the current literature. Methods: This narrative review is based on a literature search of peer-reviewed journals. We searched the databases ERIC, PsycARTICLES, PsycINFO and PSYNDEX on June 2, 2020 for peer reviewed articles published between 2000 and 2020 in English language for the preschool, school, and adolescent age (2-17 years) using the following search terms: "emotional dysregulation" OR "affect dysregulation," retrieving 943 articles. Results: The results of the literature search are presented in the following sections: the relationship between ED and psychiatric disorders (ADHD, Mood Disorders, Psychological Trauma, Posttraumatic Stress Disorder, Non-suicidal Self-Injury, Eating Disorders, Oppositional Defiant Disorder, Conduct Disorder, Disruptive Disruptive Mood Dysregulation Disorder, Personality Disorders, Substance Use Disorder, Developmental Disorders, Autism Spectrum Disorder, Psychosis and Schizophrenia, and Gaming Disorder), prevention, and treatment of ED. Conclusion: Basic conditions of ED are genetic disposition, the experience of trauma, especially sexual or physical abuse, emotional neglect in childhood or adolescence, and personal stress. ED is a complex construct and a comprehensive concept, aggravating a number of various mental disorders. Differential treatment is mandatory for individual and social functioning.