A Review on Attachment and Adolescent Substance Abuse: Empirical Evidence and Implications for Prevention and Treatment

The Role of Attachment in Gambling Behaviors and Gambling Disorder: A Systematic Review

In recent years, a growing number of attachment-based studies have contributed to the understanding of both substance and behavioral addictions. Although gambling is a form of addictive behavior widespread all over the world, both among young people and adults, the evidence on the association between attachment-related phenomena and gambling has not yet been systematized in literature. The aim of the present study, therefore, is to provide a systematic literature review aimed at summarizing the empirical evidence on this topic. Following the updated 2020 PRISMA guidelines, a systematic search in four electronic scientific databases (Scopus, PubMed, PsycInfo and Web of Science) was conducted. After removing duplicates, 146 records were double-screened, with 12 articles meeting the inclusion criteria. Additionally, by means of a backward search a further article was selected. Altogether, 13 articles were selected for the present systematic review. With few exceptions, the results underline the significant role played by attachment-related phenomena in gambling behaviors, highlighting that specific attachment contexts have a different influence on gambling, also depending on whether gamblers are youths or adults. In particular, while secure attachment has proven to be a protective factor for the onset of gambling behavior, insecure attachment has emerged to be a vulnerability factor in two ways. On the one hand, it directly favors gambling behaviors; on the other, it affects coping strategies and the individual's ability to identify and regulate emotions, which in turn predict gambling. Limitations, strengths, and implications of the present systematic review are discussed.

'Can we predict aggression?'-Determining the predictors of aggression among individuals with substance use disorder in China undergoing enforced detoxification through machine learning

BACKGROUND

The general aggression model has shown that both individual and situational factors can predict aggression. However, past research has tended to discuss these two factors separately, which might lead to inconsistency. This study addresses this gap by examining the importance of each predictor of aggression in a Chinese compulsory drug treatment population and further explores the predictors of aggression in various substance use disorder populations.

METHOD

Analyses were conducted using a sample of 894 male participants (mean = 38.30, SD = 8.38) in Chinese compulsory drug rehab. A machine learning model named LightGBM was employed to make predictions. We then used a game-theoretic explanatory technique, SHAP, to estimate the effect of predictors.

RESULTS

In the full-sample model, psychological security, parental conflict, and impulsivity were the top 3 predictors. Depression, childhood abuse, and alexithymia positively predicted aggression, whereas psychological security, family cohesion, and gratitude negatively predicted aggression. There were significant differences in the predictive effects of depressants and stimulants. Although the importance of predictors varied between drug-use groups, several individual and situational factors were consistently the most important predictors.

LIMITATIONS

All participants in this study were male, and the data were acquired through self-reports from the participants. Domestic and nondomestic aggression are not distinguished. Additionally, our findings cannot support causal conclusions.

CONCLUSION

This study tested a series of classical theories of the predictors of aggression in China's compulsory drug treatment context and extended the ideas of the GAM to various substance use disorder groups. The findings have important implications for aggression treatment.

Abnormal brain oscillations and activation of patients with heroin use disorder during emotion regulation: The role of delta- and theta-band power

BACKGROUND

Emotion dysregulation is a crucial component of substance use disorders in predisposition, maintenance, and relapse. Emotional regulation strategies are an important factor in emotion dysregulation. However, studies on heroin use disorder (HUD) patients' ability to use emotion regulation strategies are scarce.

METHODS

Time-frequency-based analyses were used to compare the power of 33 patients with HUD and 28 healthy controls to elucidate whether patients with HUD have abnormal neural oscillations during passive viewing and emotion regulation strategies. Using the standardized low-resolution brain electromagnetic tomography algorithm (sLORETA), we estimated the possible sources of the anomalous band power.

RESULTS

Compared to patients with HUD, healthy controls showed a stronger decrease in the power of the delta/theta band across all task conditions. The effect peaked at approximately 1300-1900 ms after stimulus onset and varied by task condition. The estimation of sLORETA suggested the frontal, parietal, and limbic lobes as possible generators.

LIMITATIONS

We cannot exclude the potential influence of additional factors, such as sex, depression and anxiety levels, and polysubstance use, on the results.

CONCLUSIONS

Patients with HUD have blunted arousal and impaired ability to use emotion regulation strategies. The abnormal patterns described above may be the underlying neurophysiological basis for this dysfunction. Future studies could combine different approaches to improve emotion dysregulation in patients with HUD to promote treatment outcomes.

Problematic Gambling Behavior in a Sample with Substance Use Disorder: The Role of Attachment Style and Alexithymia

Gambling disorder is a high comorbid disorder in substance abusers which conjunct appearance is related to worse symptomatology and evolution. Nevertheless, the research on the risk factors that may explain this comorbidity is scarce. We build of the self-regulation theory of attachment and addiction to examine if insecure attachment is related to gambling comorbidity in substance abuse disorder and the mediating role of alexithymia in this process. A cross-sectional study was carried out with 369 clinical patients with substance use disorder of which 69 presented comorbid gambling disorder diagnosed with the DSM-5 criteria. Results showed that insecure attachment was more prevalent in the group with comorbid gambling. In this group, the alexithymia levels were also higher and mediated the relationship in between attachment and gambling disorder comorbidity even controlling for several sociodemographic variables. This research indicates that insecure attachment enhances the risk of gambling comorbidity on substance abusers due to the detrimental effect on the self-regulation of emotion. Thus, interventions directed to increase the identification, expression and awareness of emotions might help to reduce comorbidity of gambling of substance use disorders.

Individual factors associated with the consumption of illicit substances: a review of reviews

INTRODUCTION

According to national studies, the use of illicit drugs is growing in Colombia. With this, the prevalence of substance use disorders and the set of health effects related to this practice also increases. Knowledge of the factors associated with the use of illicit drugs is necessary to guide the comprehensive care of the phenomenon.

METHODS

This is a systematic review of reviews on factors associated with the consumption of illicit drugs with seven databases and evaluation of the quality of the manuscripts according to AMSTAR.

RESULTS

Information was extracted from 38 reviews on individual factors associated with the use of illicit drugs. Demographic factors are associated with consumption through other factors. There is evidence of the association between mental and behavioural disorders and personality disorders.

CONCLUSIONS

The likelihood of consumption of illicit substances and disorders due to their use is affected by a set of personal factors including sociodemographic characteristics, mental health conditions, sexual behaviour, legal drug use, age of onset and risk perception.

The ineffective emotion regulation strategies of heroin use disorder patients: An event-related potential study

BACKGROUND

People with substance use disorders (SUDs) usually experience emotion dysregulation, which may be a consequence of or a risk factor for the development and maintenance of substance misuse. Despite growing evidence on emotion dysregulation among people with SUDs, relatively few studies have explored emotion dysregulation in heroin use disorder (HUD) patients.

METHODS

Using event-related potentials (ERP), we compared the emotion regulation ability of 33 HUD patients and 30 healthy controls according to their average electroencephalogram amplitudes of the late positive potential (LPP) component in 400-1000 ms and 1000-2000 ms time windows, while viewing neutral and unpleasant emotional pictures, and using emotion regulation strategies (expressive suppression, cognitive reappraisal, and a combination) while viewing unpleasant pictures. We recorded their mood states and how successfully they used emotion regulation strategies in each block using 7-point scales.

RESULTS

Relative to healthy controls, the LPP amplitudes of HUD patients were significantly lower when viewing emotional stimuli (p_earlyLPP < 0.05) and using emotion regulation strategies (all p < 0.05). The left hemisphere was more active in healthy controls (p_earlyLPP < 0.05, p_lateLPP < 0.01); there were no differences in scalp position activation among HUD patients.

DISCUSSION

Compared to healthy controls, HUD patients' emotional arousal and emotion regulation ability were impaired, as reflected by the LPP component. Their abnormal scalp activation pattern may imply abnormal brain activity. Future research could explore this with electroencephalogram source analysis techniques, functional magnetic resonance imaging, or other technologies. Intervention effects for emotion dysregulation in HUD treatment are also worth exploring.

A Grounded Theory Study: How Non-Treatment-Seeking Substance Users Make Sense of Their Behaviour “I Want To Be Me but I Don’t Know Who Me Is”

Despite the global impact of substance misuse, there are inadequate levels of specialist service provision and continued difficulties with treatment engagement. Within policy and research, there is substantial consideration of the importance of these factors. However, there is little empirical evidence of the views of non-treatment-seeking substance users, who make up the majority of the substance using population. The aim of this study was to understand how these individuals make sense of their behaviour and their reasons for not accessing treatment. A constructivist grounded theory approach was used to interview eight individuals who were currently using substances and not seeking help to stop. The analysis highlighted the importance of attachment to an identity associated with substance use, and relational variables such as connectedness to others, for treatment decisions for individuals who use substances. Understanding these influences, through trauma- and attachment-informed service provision, may reduce barriers to help-seeking and improve treatment uptake.

The Roles of Attachment Style, Self-Efficacy, and Impulsivity on the Prediction of Attitudes toward Substance Use in Male Adolescents

The aim of this study was to examine the role of attachment styles, self-efficacy, and impulsivity on the prediction of attitudes toward substance abuse among male adolescents. Participants were 199 male adolescents from Najafabad City, Isfahan province, Iran. A demographic questionnaire, the Attachment Style Measure (ASM), the General Self-Efficacy Scale (GSES), the Barratt Impulsiveness Scale (BIS), and the Attitude toward Substance Use Scale (ASUS) were used in this study. Analysis showed that avoidance and ambivalent attachment patterns and impulsiveness were significantly positively correlated with attitudes toward substance use. On the other hand, secure attachment style and self-efficacy were significantly negatively associated with attitudes toward substance use. Findings showed that attachment styles, self-efficacy, and impulsiveness account for 58% of the variance in attitudes toward substance use among these adolescents. This study confirmed the predictive role of attachment styles, self-efficacy, and impulsivity in the prediction of the attitudes toward substance use in male adolescents.

Psychosocial Factors Predict the Level of Aggression of People with Drug Addiction: A Machine Learning Approach

This study aimed to identify the relevant psychosocial factors that can predict the aggression in people with drug addiction. A total of 896 male participants (Mean_age = 38.30 years) completed the survey. Gradient boosting regression, a machine learning algorithm, was used to find the relevant psychosocial variables, such as psychological security, psychological capital, interpersonal trust and alexithymia, that may be significantly related to aggressive behavior. Results showed that the five most important factors in the prediction of aggression are interpersonal trust, psychological security, psychological capital, parental conflict and alexithymia. A high level of interpersonal trust, psychological security and psychological capital can predict a low level of aggression in people with drug addiction, while a high level of parental conflict and alexithymia can predict a high level of aggression. Overall, the findings highlight the need to focus interventions according to the relation between these psychosocial factors and aggression in order to decrease violence.

Maternal pre- and postnatal substance use and attachment in young children: A systematic review and meta-analysis

Maternal substance use has often been associated with insecure and disorganized child attachment. We evaluated this association with a meta-analysis of young children and, further, systematically reviewed mediating and moderating factors between maternal substance use and child attachment. We performed a systematic database search of quantitative English language studies on child attachment that included substance-using mothers and their children below 6 years of age. Eleven studies (N = 1,841) met the inclusion criteria and were included in the meta-analysis of attachment security and seven (N = 1,589) studies were included in the meta-analysis of attachment disorganization. We found that maternal substance use was negatively associated with secure attachment in children, but the effect size was small (r = -.10). The association with disorganized attachment was not significant (r = .15). Related to moderating and mediating factors (k = 6), we found evidence on the role of teratogenic and sociological factors on child attachment. Most importantly, the impact of cumulative risks was vital. However, literature was scarce, and studies varied in risk of bias, leaving many unanswered questions on other potential factors underlying the development of attachment in these high-risk children. We discuss the results considering clinical implications and future directions.

The role of the working alliance in psychological treatment of substance use disorder outpatients

Objective: The main objective of this study was to explore the relationship between alliance and treatment outcome of substance use disorder (SUD) outpatients in routine care. Attachment, type of substance use, and treatment orientation were analyzed as potential moderators of this relationship.Method: Ninety-nine SUD outpatients rated their psychological distress before every session. Patients and therapists rated the alliance after every session. At treatment start and end, the patient completed the Alcohol Use Disorders Identification Test (AUDIT), the Drug Use Disorders Identification Test (DUDIT), and the Experiences in Close Relationships (ECR-S). Data were analyzed using multilevel growth curve modeling and Dynamic Structural Equation Modeling (DSEM).Results: The associations between alliance and outcome on psychological distress and substance use were, on average, weak. Within-patient associations between patient-rated alliance and outcome were moderated by self-rated attachment. Type of abuse moderated associations between therapist-rated alliance and psychological distress. No moderating effect was found for treatment orientation.Conclusions: Patients' attachment style and type of abuse may have influenced the association between alliance and problem reduction. A larger sample size is needed to confirm these findings.

Pinpointing Neural Correlates of Attachment in Poly-Drug Use: A Diffusion Tensor Imaging Study

An increasing amount of evidence indicates the significance of attachment in the etiology of poly-drug use disorder (PUD). The aim of this study was to investigate associations between PUD and adult attachment in particular, with a focus on white matter (WM) fiber tract integrity. For this purpose, we selected several regions-of-interest based on previous findings which were examined for their role in PUD and estimated whole-brain associations between adult attachment and WM integrity. A total sample of 144 right-handed males were investigated (Age: M = 27; SD = 4.66). This included a group of patients diagnosed with PUD (n = 70) and a group of healthy controls (HC; n = 74). The Adult Attachment Scales (AAS) was applied to assess attachment attitudes in participants. Diffusion Tensor Imaging was used to investigate differences in WM integrity. The findings suggest substantially less attachment security in PUD patients compared to HC. Furthermore, PUD patients exhibited reduced integrity in WM fiber tracts, most pronounced in the bilateral corticospinal tract, the fronto-occipital fasciculus, and the right inferior longitudinal fasciculus. However, these results were not controlled for comorbid depressiveness. With regard to associations between adult attachment and WM integrity, the results for PUD patients indicate a negative relationship between "Comfort with Closeness" and the structural integrity of a cluster comprising parts of the right anterior thalamic radiation, the inferior fronto-occipital fasciculus and the uncinate fasciculus. Despite being limited by the cross-sectional design of this study, the results emphasize the significance of attachment in PUD etiology, both at a behavioral and a neurological level. Largely in line with previous research, the findings revealed tentative links between adult attachment and WM fiber tracts related to cognitive and affective functions in PUD patients.

Childhood Trauma, Personality, and Substance Use Disorder: The Development of a Neuropsychoanalytic Addiction Model

BACKGROUND

While traditional psychoanalysis has been criticized as insufficient for the treatment of substance use disorder (SUD), recent progress in the field of neuropsychoanalysis has generated new and promising hypotheses regarding its etiology. However, empirical research applying this framework has been sparse.

AIM AND SCOPE

The present overview aims at developing and empirically validating a neuroscientifically informed psychodynamic framework regarding the etiology of SUD. For this purpose, this review provides a concise overview of the most relevant historical and contemporary psychoanalytic theories on SUD etiology. Furthermore, the original research summarized in this paper consists of three studies investigating connections between childhood trauma, primary emotions, personality structure and attachment, as well as their relation to SUD development and treatment.

CONCLUSIONS

The results highlight the empirical validity of the neuropsychoanalytic approach towards SUD etiology. In particular, the findings underscore the conceptualization of SUD as a disorder related to dysfunctional attachment and affect regulation abilities especially linked to increased SADNESS and ANGER dispositions, which mediated the relationship between SUD and traumatic childhood relationships. Based on these findings, a refined model of SUD etiology is proposed, which should be tested in future studies.

Individual Factors Associated with the Consumption of Illicit Substances: a Review of Reviews

INTRODUCTION

According to national studies, the use of illicit drugs is growing in Colombia. With this, the prevalence of substance use disorders and the set of health effects related to this practice also increases. Knowledge of the factors associated with the use of illicit drugs is necessary to guide the comprehensive care of the phenomenon.

METHODS

This is a systematic review of reviews on factors associated with the consumption of illicit drugs with seven databases and evaluation of the quality of the manuscripts according to AMSTAR.

RESULTS

Information was extracted from 38 reviews on individual factors associated with the use of illicit drugs. Demographic factors are associated with consumption through other factors. There is evidence of the association between mental and behavioural disorders and personality disorders.

CONCLUSIONS

The likelihood of consumption of illicit substances and disorders due to their use is affected by a set of personal factors including sociodemographic characteristics, mental health conditions, sexual behaviour, legal drug use, age of onset and risk perception.

The Influence of an Attachment-Related Stimulus on Oxytocin Reactivity in Poly-Drug Users Undergoing Maintenance Therapy Compared to Healthy Controls

BACKGROUND

Substance use disorders (SUDs) have been described as a dysfunctional way to compensate for deficiencies in that person's underlying attachment system. Furthermore, the neuropeptide oxytocin (OT), which is a critical component of the neurobiology of the attachment system, has been shown to effectively reduce addictive behavior and therefore has been discussed as a potential medication in SUD treatment. This study investigates variation in peripheral OT plasma levels as a function of exposure to an attachment-related stimulus in SUD patients compared to healthy controls (HCs).

METHODS

A total sample of 48 men, 24 inpatients in maintenance treatment who were diagnosed with poly-drug use disorder (PUD) and 24 HC, was investigated. A 15-min exposure to the Adult Attachment Projective Picture System (AAP) was used as an attachment-related stimulus and coded for attachment status. Blood samples before and after the AAP-assessment were taken and assayed for OT levels. Variation in baselines level of OT was examined in relation to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), the Adult Attachment-Scale (AAS), and the Brief Symptom Inventory (BSI).

RESULTS

Following the AAP stimulus controls showed no significant difference in OT levels elevation from baseline compared to the PUD group's OT levels. Furthermore, in the PUD group only OT-baseline-levels may be negatively associated with the AAS subscale "Comfort with Closeness" and "Anxiety" and lifetime substance use.

DISCUSSION

Our results suggest that peripheral OT levels in poly-drug users undergoing maintenance treatment are not significantly different in responsiveness to an attachment related stimulus compared to HC. With regard to non-significant tendencies observed in this study which hint toward decreased OT-reactivity in the PUD group, further research is needed to explore this hypothesis with increased statistical power.

Using a Developmental-Relational Approach to Understand the Impact of Interpersonal Violence in Women Who Struggle with Substance Use

Substance use among women is a major public health concern. This review article takes a developmental-relational approach to examine processes through which early relational trauma and violence in relationships may lead to substance use. We examine how early exposure to violence in relationships can impact neurological development, specifically through interference with physiological mechanisms (e.g., the hypothalamic-pituitary-adrenal axis), brain structure and functioning (e.g., the hippocampus and prefrontal cortex), and neuropsychological development (e.g., executive functioning and emotion regulation) across the lifespan. Further, we discuss the impact of exposure to violence on the development of relational capacity, including attachment, internal working models, and subsequent interpersonal relationships across the lifespan, and how these developmental pathways can lead to continued problematic substance use in women.

Mothering, Substance Use Disorders and Intergenerational Trauma Transmission: An Attachment-Based Perspective

Background: A growing body of research underlines that interpersonal trauma in childhood leads to heightened susceptibility for substance use disorders (SUDs) in later life. Little research has been conducted on parenting experiences of mothers in recovery from substance use, taking into account their own upbringing as a child and the potential aftermath of interpersonal childhood trauma. Methods: Through in-depth qualitative interviews, 23 mothers with SUDs reflected on parenting experiences and parent-child bonding, related to both their children and parents. Interviews were transcribed verbatim and data were analyzed adopting thematic analysis. Results: Throughout the narratives, consequences of trauma on mothers' sense of self and its subsequent impact on parenting arose as salient themes. Five latent mechanisms of intergenerational trauma transmission were identified: 1) early interpersonal childhood trauma experiences in mothers; 2) trauma as a precursor of substance use; 3) substance use as a (self-fooling) enabler of parental functioning; 4) continued substance use impacting parental functioning; and 5) dysfunctional parental functioning and its relational impact upon offspring. Discussion: Findings suggest disruptive attachment can increase the vulnerability for SUDs on the one hand, but can be an expression of underlying trauma on the other, hence serving as a covert mechanism by which trauma can be transmitted across generations. Results indicate the need for preventive, attachment-based and trauma-sensitive interventions targeted at disruptive intergenerational patterns.

A preliminary study of early childhood parenting and adult past month drug use risk in low-income African American women

PURPOSE

This preliminary study was designed to assess the feasibility of examining early childhood parenting factors and their relationship with adult past month drug use among low-income African American women.

METHODS

A cross-sectional survey of 156 low-income African American women was conducted. Measures included the childhood parental bonding scale, frequency of exposure to corporal punishment (CP) in childhood, The Drug Abuse Screening Test (DAST) and The Differentiation of Self Scale. Structural equation modeling (SEM) was used to assess the relationship between the primary predictors, latent parental bonding and corporal punishment exposure, with past month drug use. The intermediary construct, emotional reactivity, was also included in the SEM model to test mechanisms of mediation.

RESULTS

There was a significant main effect for maternal care on lower emotional reactivity patterns in adulthood. There was also a significant main effect for frequent CP on higher emotional reactivity patterns in adulthood. The relationship between both parenting measures and drug use were mediated by emotional reactivity.

CONCLUSION

Childhood maternal factors are a strong predictor of adult past month drug use, and this may be accounted for, in part, by the influence that parenting patterns in childhood have on adult emotional reactivity patterns. These observations should be examined in a longitudinal study to determine the stability of our observation that CP in childhood, even when controlling for positive maternal bonding patterns, influences emotional reactivity patterns that predispose an individual to negative coping strategies, such as drug use, in adulthood, among low-income African American women.

The Role of Attachment in Poly-Drug Use Disorder: An Overview of the Literature, Recent Findings and Clinical Implications

Background: Substance use disorders (SUDs) represent a worldwide epidemic with extensive costs to the individual and to society. Occasionally described as an attachment disorder, they have been linked to various impairments in self-regulation and social functioning. However, while there have been significant advances in the development and validation of treatment strategies for SUD in recent years, the components of these treatment approaches have yet to be fully explored. The characteristics of polydrug use disorder (PUD) especially need to be addressed in more detail, as this diagnosis is highly common in individuals seeking treatment, while simultaneously being associated with poor treatment success. Aim and Scope: This review aims at further exploring the relevance of attachment in PUD and its treatment. To this end, this review provides a concise summary of relevant theories on the development and treatment of SUD in general, including related parameters of attachment, emotion regulation, and neuroscience. Furthermore, several studies focused specifically on PUD are described in more detail. These studies explored the connections between attachment, personality structure, primary and higher emotions (including spirituality), as well as structural and functional neural parameters in inpatients with PUD as well as in healthy controls. Most notably, the described studies highlight that insecure attachment and impairments in personality structure are present in inpatients with PUD. In addition, these characteristics are paralleled by extensive impairments in white matter integrity, especially in tracts connected to facets of emotion regulation. Conclusions: Based on our findings, we emphasize conceptualization of PUD as an Attachment Disorder, on a behavioral as well as on a neural level. Furthermore, we point out the importance of an integrated bio-psycho-social approach in this research area. Consequently, future studies might more closely focus on the influence of attachment-based interventions on emotion regulation abilities as well as a potentially related neuroplasticity. Neuroplastic changes, which are still rather unexplored, might represent important parameters for the assessment of treatment outcomes especially in long-term SUD treatment.

[Addiction as an attachment disorder]

BACKGROUND

There is no commonly accepted model for describing the development and treatment of substance use disorders (SUD); however, over several decades the attachment theory has represented an important basis for the clinical handling of SUD. This study gives a systematic review of empirical studies regarding the relationship between SUD and disorders of attachment behavior.

OBJECTIVE

Is there a positive relationship between disorders of attachment behavior and the presence of SUD?

METHOD

Various databases (PsychInfo, Web of Science, PubMed) were systematically searched in order to pinpoint relevant studies in books and articles published in English or German. Based on the results 22 publications were selected. After a stricter limitation to original research, 12 articles could finally be accepted as eligible.

RESULTS

A significant relationship was found between SUD and insecure attachment in 10 out of the 12 studies.

CONCLUSION

Based on the results of the research studies reviewed the hypothesis to characterize SUD as a possible expression of an attachment disorder was confirmed. This corroborates the importance of considering attachment parameters in dealing with prevention and treatment of SUD. Further research might focus on non-substance-related addictive disorders and therapy outcome studies.

[Current State of Family-Based Prevention and Therapy of Substance-Use Disorders in Children and Adolescents: A Review]

Current State of Family-Based Prevention and Therapy of Substance-Use Disorders in Children and Adolescents: A Review Adolescence is a vulnerable period for substance use disorders (SUD) as indicated by epidemiological studies. Research demonstrates the family's role for the etiology of SUD and provides a rationale for interventions based on family-associated risk and resilience factors. In this article, we summarize published results for family-based interventions from 2008-2018. Taken together, prevention programs can be effective when they focus on the promotion of broader developmental competencies and familial resources, rather than narrowly addressing substance use. Moreover, programs could benefit from targeting youth and parents as done in the "Strengthening Families Program 10-14"; most existing programs however target parents and do not include the adolescents. Family-based treatment programs with an evidence base are Multisystemic Therapy, Functional Family Therapy, Multidimensional Family Therapy and Brief Strategic Family Therapy. Overall, the effects of family-based interventions are small-to-middle sized but vary significantly across populations. Across the field of family-based interventions, there is a need for more knowledge on effective components and differential effects. The results could be improved by translational research such as on the emerging concept of mindfulness. Moreover, there is a need for implementation research and the effectiveness of service delivery programs on the community level in Germany.

Frustration Tolerance and Personality Traits in Patients With Substance Use Disorders

Previous research has suggested the prevalence of certain personality traits, some of which are related to a disorganized attachment, in substance abuse disorders. Further, frustration tolerance (FT) has been proposed as an important factor in addiction, both at the inception-following the "self-medication" hypothesis-and regarding treatment compliance. In turn, an inadequate response to frustrating events has been also associated with a disrupted attachment. Our goal is to explore the mediational role of FT in the relationship between personality traits and two different treatments for substance addiction: therapeutic community (TC) and ambulatory treatment (AT). Eighty-four subjects with substance abuse disorder were recruited in total (22 female), including 46 volunteers (13 female) in TC and 38 (9 female) in AT. They were assessed with Rosenzweig's test for FT and the Millon Clinical Multiaxial Inventory-III (MCMI-III) test to evaluate personality factors. By comparing with a control sample (335 volunteers, 268 female), we found that FT was lower in patients. Between therapeutic groups, FT was significantly lower in TC. Depressive, antisocial, sadistic, negativistic, schizotypal, borderline, paranoid, anxiety, dysthymia, alcohol use, drug use, posttraumatic stress disorder (PTSD), thought disorder, and delusional disorder traits were suggestive of pathology in the clinical samples and were significantly different between control, AT, and TC groups. Further, anxiety and PTSD traits were higher in TC than in AT. A mediational analysis revealed that the effect of anxiety and PTSD scales on therapeutic group was partially mediated by FT. In conclusion, FT and its interplay with personality traits commonly related to disorganized attachment (anxiety and PTSD) might be important factors to consider within therapeutic programs for persons with substance addiction.

Maltreatment, attachment, and substance use in adolescence: Direct and indirect pathways

Past research indicates that maltreatment increases risk for adolescent substance use; however, research is limited on how attachment between adolescents and their parents influences this relationship. The present study examined psychological and physical maltreatment, attachment avoidance and attachment anxiety, and substance use (i.e., cigarettes, alcohol, marijuana, and 'other drugs') among adolescents between the ages of 12 and 18 (N = 737; 59.3% female; Mage = 14.69, SD = 1.46). Psychological maltreatment was significantly related to cigarettes, alcohol, and marijuana use, and physical maltreatment was related to cigarette and marijuana use. Exposure to both forms of maltreatment was also associated with increased attachment avoidance and attachment anxiety, but only attachment avoidance predicted substance use. Indirect paths indicated that attachment avoidance mediated the relationship between psychological maltreatment and cigarette (B = 0.14, CI [0.001, 0.314]) and alcohol use (B = 0.09, CI [0.011, 0.188]). Attachment avoidance also mediated the relationship between physical maltreatment and cigarette (B = 0.15, CI [0.031, 0.311]) and alcohol use (B = 0.09, CI [0.027, 0.185]). No significant mediated effects for attachment anxiety emerged. Attachment avoidance may increase risk for substance use because youth have a lower rate of disclosing their activities to their parents, and do not seek or accept their guidance. Instead, they may turn to peers who also engage in substance use as a source of support. Interventions designed to increase parent-teen attachment security and decrease attachment avoidance may be particularly useful in reducing risk for substance use.

Attachment and Substance Use Disorders-Theoretical Models, Empirical Evidence, and Implications for Treatment

Introduction: The article reviews attachment-oriented research in individuals with substance use disorders (SUDs). Based on attachment theory, substance abuse can be understood as "self-medication," as an attempt to compensate for lacking attachment strategies. Attachment theory suggests a developmental pathway from insecure attachment to SUD and, on the other hand, a negative impact of substance abuse on attachment security. Earlier reviews have indicated a general link but have been inconclusive with regard to other aspects. In the light of a growing body of research, this review is looking for evidence for the general link, for its direction, for differences due to different patterns of attachment, different substances and severities, comorbid psychiatric disorders, and age groups. Methods: Using medical and psychological databases, 34 cross-sectional studies, three longitudinal studies, and a systematic meta-analysis were identified. Methodological problems such as poor assessment of SUD and the use of different measures of attachment limit comparability. Results: All cross-sectional studies in the review confirm a link between insecure attachment and SUD. Results of longitudinal studies show insecure attachment to be a risk factor for SUD, while continued substance abuse impairs the ability to form close relationships. With regard to specific patterns of attachment, results mainly point toward very insecure patterns. They indicate different patterns of attachment in different groups of substance abusers, suggesting different developmental pathways. Fearful-avoidant attachment was frequent in heroin addicts, while alcohol abusers displayed more heterogeneous patterns. Comorbid mental disorders and severity of SUD seem to be important factors, but data are still inconclusive. The link between insecure attachment and SUD seems to be stronger in adolescence compared to adulthood. Discussion: The last decades have seen a substantial growth in studies on attachment and SUDs. Despite methodological problems, the general link between insecure attachment and SUD today is well established. Attachment theory might contribute to the understanding and treatment of SUDs in a significant way. But to do so, a lot of open questions have to be answered. We will need more carefully designed longitudinal studies, more studies connecting psychological data with brain processes, and more clinical trials.

Attachment-Based Family Therapy for Adolescent Substance Use: A Move to the Level of Systems

This paper provides an account of the theoretical basis of a family-based intervention called Behaviour Exchange and Systems Therapy (BEST). The model described here has also been applied to adolescents with substance abuse and other mental health problems such as depression and anxiety disorders in both children and adolescents. Evaluative studies of the model have been published including randomised clinical trials as well as qualitative analyses. The current paper discusses a theory of the family system as a discourse and represents an integration of aspects of attachment, psychoanalytic, and systems theories. Key concepts elaborated are the attachment-family system, the family as a single discourse, the use of segregation as a defense in relation to trauma and loss and its manifestation in a family narrative, and the role of the family secure base in affect regulation. The paper also briefly describes specific treatment techniques that are derived from the theoretical model. Our approach has wide application as a discourse focused treatment for children and adolescents using a family systems approach. Future work requires the comparison of this model to similar attachment-based models of intervention for children and families, further development and validation of measures able to be used for whole families in a clinical setting, and further empirical demonstration of treatment efficacy in a variety of clinical settings.

Attachment style among outpatients with substance use disorders in psychological treatment

OBJECTIVES

To explore the associations between self-rated attachment style, psychological distress and substance use among substance use disorder (SUD) outpatients in psychological treatment.

DESIGN AND METHODS

In this practice-based study, 108 outpatients were asked to fill in the Experiences in Close Relationships - Short form, the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), the Alcohol Use Disorders Identification Test (AUDIT), and the Drug Use Disorders Identification Test (DUDIT) at treatment start and end. Patients were given psychological treatments with a directive, reflective or supportive orientation.

RESULTS

An insecure attachment style was more common among the SUD outpatients, compared to non-clinical groups. Patients with a fearful attachment style scored higher on psychological distress than patients with a secure attachment style. The associations between the attachment dimensions and psychological distress were stronger than those between attachment and SUD. Significantly more patients had a secure attachment style at treatment end.

CONCLUSIONS

This study shows significant relations between patients' attachment style and their initial psychological distress. The causal relationship between attachment style and psychological distress is, however, not clear and can likely go in both directions. The psychological treatment of patients with SUD contributed significantly to changes from insecure to secure attachment style.

PRACTITIONER POINTS

We found among patients with SUD a strong relation between patients' attachment style and their psychological distress. Knowledge of the patient's attachment style may help the therapist to tailor the treatment to the patient's needs. A change from insecure to secure attachment style can be an important goal for a SUD treatment, as it may prevent the patient from using defence strategies involving substance use for regulating emotions and interpersonal relationships.

A developmental model of addictions: integrating neurobiological and psychodynamic theories through the lens of attachment

Although substance use and abuse may impact brain and behavior, it is still unclear why some people become addicted while others do not. Neuroscientific theories explain addiction as a series of between- and within-system neuroadaptations that lead to an increasingly dysregulating cycle, affecting reward, motivation, and executive control systems. In contrast, psychoanalysis understands addiction through a relational perspective wherein there is an underlying failure in affect regulation, a capacity shaped early developmentally. Considering recent findings suggesting the neurobiological overlap of addiction and attachment, it may be possible to integrate both perspectives into a developmental model through the lens of attachment. The goal of the present review is to evaluate the value of neurobiological and psychodynamic perspectives to inform our understanding of addiction, particularly substance-use disorders.

Increased attachment security is related to early therapy drop-out in substance use disorders

OBJECTIVES

Previous research work suggests a positive association between secure attachment and increased therapy adherence (TA) in different patient groups. However, there is still a strong need for research focusing on the influence of attachment on TA in substance use disorder (SUD) treatment. Hence, this study attempts to investigate the predictive value of different attachment patterns concerning TA in SUD inpatients.

RESULTS

122 (34 female) SUD inpatients completed the Attachment Style Questionnaire (ASQ) during the entry phase of therapeutic community treatment. After 6 weeks, subjects who remained in therapy (n = 47) completed the ASQ for a second time. In line with the literature, agglomerative Cluster Analysis suggested a two-cluster solution (Cluster I: increased secure attachment pattern; Cluster II: increased insecure attachment pattern). Notably, inpatients in Cluster I were more likely to drop out of treatment within the first 6 weeks (p < .001). Furthermore, subjects showed less "Confidence in Self and Others" (p < .05) after 6 weeks of treatment. Our findings indicate a negative predictive value of increased attachment security for TA in SUD inpatients. This finding probably mirrors a more realistic kind of self-assessment. More generally, the importance of considering attachment styles in SUD treatment is underlined.

Addiction as an Attachment Disorder: White Matter Impairment Is Linked to Increased Negative Affective States in Poly-Drug Use

Substance use disorders (SUD) have been shown to be linked to various neuronal and behavioral impairments. In this study, we investigate whether there is a connection between the integrity of white matter (WM) and attachment styles as well as different affective states including spirituality in a group of patients diagnosed for poly-drug use disorder (PUD) in comparison to non-clinical controls. A total sample of 59 right-handed men, comprising the groups of patients with PUD (n = 19), recreational drug-using individuals (RUC; n = 20) as well as non-drug using controls were recruited (NUC; n = 20). For the behavioral assessment, we applied the Adult Attachment-Scale, the Affective Neuroscience Personality-Scale (short version) and the Multidimensional Inventory for Religious/Spiritual Well-Being. Diffusion Tensor Imaging was used to investigate differences in WM neural connectivity. Analyses revealed decreased Fractional Anisotropy and decreased Mean Diffusivity in PUD patients as compared to RUC and NUC. No differences were found between RUC and NUC. Additional ROI analyses suggested that WM impairment in the superior longitudinal fasciculus (SLF) and the superior corona radiata (SCR) was linked to more insecure attachment as well as to more negative affectivity. No substantial correlation was observed with spirituality. These findings are mainly limited by the cross-sectional design of the study. However, our preliminary results support the idea of addiction as an attachment disorder, both at neuronal and behavioral levels. Further research might be focused on the changes of insecure attachment patterns in SUD treatment and their correlation with changes in the brain.

Attachment in the Psychiatric Curriculum

Psychiatric trainees are expected to learn the fundamental concepts of psychodynamic psychotherapy, but they often struggle to understand and appreciate the relevance of this work. An introduction to attachment theory can go a long way toward assisting our trainees in understanding the relevance of psychodynamic psychiatry. To help programs develop this component of their curriculum, we summarize the history of the development of the attachment paradigm including the Strange Situation and Adult Attachment Interview (AAI), useful tools to teach these concepts, as well as ramifications of this work. We provide a summary of information regarding the evidence base connected to this paradigm, potential clinical relevance, health implications, work from neuroscience, and infant intervention models to assist in bringing psychodynamic concepts to life. Exposure to the attachment paradigm provides a model of intervention, prevention, and hope for our trainees as they transition from learning phenomenologic models of psychiatric diagnostics to other paradigms of human development and intervention.

Exploring the Link among State of Mind Concerning Childhood Attachment, Attachment in Close Relationships, Parental Bonding, and Psychopathological Symptoms in Substance Users

Background: In the present study, we have explored the link among styles of attachment and psychopathology in drug users. We know that insecure attachment predisposes the individuals the development of drug-addiction and psychopathological symptoms. However, we do not know which attachment is more frequent in drug users and which is related to particular psychopathological symptoms. The aim of the present work is to explore the relationship between childhood attachment state of mind, attachment in close relationships, parental bonding and psychopathology in sample of Italian substance users.

Methods: We explored, in a sample of 70 drug users and drug-addicted patients, the childhood attachment state of mind measured by the Adult Attachment Interview, the attachment in close relationships by the Relationship Questionnaire and parental bonding measured by the Parental Bonding Instrument. The Symptom Check-List-90-R (SCL-90-R) measured psychopathological symptoms.

Results: We found that parental bonding, rather than state of mind concerning childhood attachment or attachment in close relationships, is related to the psychopathological manifestation of anxiety, hostility, depression, and paranoid ideation in the sample. The latter occurs frequently in our sample, independent of state of mind concerning child attachment, attachment in close relationships, and parental bonding, suggesting its role either as a factor that favors a bad image of the participants’ own relationships or as a direct effect of consuming drugs.

Conclusion: These results have clinical implications on suggesting ways of interventions that prevent drug-addiction, which should include the evaluation of attachment in the prodromic phases of substance use onset or rehabilitation programs to prevent and manage psychotic-like symptoms.