Assessing attachment cognitions and their associations with depression in youth with eating or drug misuse disorders

Attachment in individuals with eating disorders compared to community controls: A systematic review and meta-analysis

OBJECTIVE

Individuals with eating disorders are known to have higher rates of insecure attachment compared to community controls, but the factors underlying this finding are poorly understood. We conducted the first meta-analysis comparing attachment in eating disorder samples compared to community controls that included quality assessment, publication bias and moderation analysis.

METHOD

We pre-registered our meta-analysis (CRD42019146799) and followed PRISMA guidelines. We searched PsychINFO, Embase, Medline, CINAHL, and Scopus for publications. Attachment scores were extracted, and Cohen's d calculated for each study using a random effects model.

RESULTS

In total, 35 studies were included in the meta-analysis and six studies were summarized in a narrative review. Eating disorder samples showed higher rates of insecure attachment compared to community controls, with a large effect size, across measurement methods and different attachment dimensions. Blinding of assessors moderated effect sizes for attachment interview studies, but no other moderators were significant.

DISCUSSION

Risk of insecure attachment is elevated in individuals with eating disorders, albeit heterogeneity is high and largely unexplained. Clinicians may need to take this into account in their work, particularly given the association between attachment insecurity and challenges to therapeutic alliance. Future studies comparing eating disorder samples with community samples should control for general psychopathology.

PUBLIC SIGNIFICANCE

Attachment is a broad concept referring to a person's thoughts, feelings and behaviors in relation to close others. This systematic review and meta-analysis found that individuals with eating disorders are lower in attachment security than community controls, regardless of attachment construct or measurement approach. Attachment may be relevant in influencing eating disorder recovery, the development of therapeutic alliance, and potentially clinical outcomes, although more research is needed.

Early parent-child interactions and substance use disorder: An attachment perspective on a biopsychosocial entanglement

This review aims to elucidate environmental and genetic factors, as well as their epigenetic and neuroendocrine moderators, that may underlie the association between early childhood experiences and Substance Use Disorders (SUD), through the lens of parental attachment. Here we review those attachment-related studies that examined the monoaminergic systems, the hypothalamic pituitary adrenal stress response system, the oxytoninergic system, and the endogenous opioid system from a genetic, epigenetic, and neuroendocrine perspective. Overall, the selected studies point to a moderating effect of insecure attachment between genetic vulnerability and SUD, reasonably through epigenetic modifications. Preliminary evidence suggests that vulnerability to SUDs is related with hypo-methylation (e.g. hyper-expression) of high-risk polymorphisms on the monoaminergic and hypothalamic pituitary adrenal system and hyper-methylation (e.g. hypo-expressions) of protective polymorphisms on the opioid and oxytocin system. These epigenetic modifications may induce a cascade of neuroendocrine changes contributing to the subclinical and behavioural manifestations that precede the clinical onset of SUD. Protective and supportive parenting could hence represent a key therapeutic target to prevent addiction and moderate insecure attachment.

Attachment Picture Story (APS)

Abstract. The Attachment Pictures Story (APS) is an adaptation of the Patte Noire thematic projective test to evaluate internal representations of attachment in adolescents. It consists in analyzing the responses to the stories in seven selected pictures, which elicit attachment experiences. The purpose of this study is to describe the development and verification of the reliability and validity parameters of the APS based on a sample of 77 adolescents between the ages of 12 and 18 years ( M = 14.71; SD = 2.07) who were enrolled in schools in Spain. The results show evidence of the instrument’s psychometric properties. Satisfactory content validity through inter-rater agreement of four experts for pictures and items as well as suitable reliability indexes were found. The exploratory factory analysis confirms the five pre-established categories based on theory (secure/insecure avoidant, insecure fearful, insecure resistant, and unresolved). The APS appears to be a psychometrically suitable instrument for evaluating attachment patterns in adolescents in a quantitative and qualitative way. Having a specific projective test that helps us understand adolescents may be useful in facilitating the expression of early and sometimes adverse attachment relationships, which are difficult to externalize.

Comparison of functional dyspepsia with organic dyspepsia in terms of attachment patterns

AIM

Functional dyspepsia, originates from gastroduodenal region, is described as resistant and recurring dyspeptic symptoms with unknown etiology. Although there is some evidence in support of a relationship between functional dyspepsia and psychopathology, attachment patterns of functional dyspepsia patients have not been studied yet. In our study, we aimed to compare attachment patterns of functional dyspepsia patients with organic dyspepsia patients and healthy volunteers.

METHOD

43 patients diagnosed with functional dyspepsia, 38 patients with organic dyspepsia and 42 healthy volunteers matched in terms of age, sex and education were included in the study. All participants were evaluated using a socio-demographic and clinical data questionnaire, the State and Trait Anxiety Inventory, the Experiences in Close Relationships Questionnaire and the Adult Attachment Scale.

RESULTS

There was no difference in sociodemographic features among the three groups. Functional dyspepsia group exhibited significantly higher Trait Anxiety scores compared to organic dyspepsia and control groups. Control group showed significantly higher secure attachment styles compared to functional dyspepsia and organic dyspepsia groups, there was no difference between groups in non-secure attachment styles according to triple attachment model. Dimensionally, functional dyspepsia group showed more avoidant attachment patterns than organic dyspepsia groups and organic dyspepsia group showed more avoidant attachment patterns than control group.

CONCLUSION

According to our findings, Functional dyspepsia patients are more anxious than organic dyspepsia patients and healthy volunteers. Non-secure attachment patterns were seen generally in all dyspeptic patients while avoidant attachment patterns are more prominent in functional dyspepsia patients.

The Factor Structure of the CA-MIR as Evaluated Using Confirmatory Factor Analysis

Introduction: The aim of the current study was to evaluate the factor structure of the CArtes- Modèles Individuels de Relations (CA-MIR), a self-report questionnaire designed to tap into the relational strategies of adults that was developed by a French-speaking research group coordinated by Blaise Pierrehumbert. The CA-MIR's particular merit lies in the richness and complexity of the theoretical model underpinning it. However, to date, this model has only been partially reproduced in studies using exploratory analysis and has never been tested via confirmatory factor analysis (CFA). Objective and Method: We thus conducted CFA on data collected from a sample of 979 subjects, recruited using a snowball sampling method during the spring and fall of 2005. To assess if some item multidimensionality was present, we estimated both the independent clusters model (ICM-CFA) and a model in which some zero loading restrictions were removed. Results: The results supported the originally proposed structure of the CA-MIR; the large majority of items were good indicators of the expected latent dimensions and only few items showed relevant secondary loadings or loaded in an unexpected factor. The instrument adequately differentiates the three attachment styles, taking into account both past and present experiences of attachment relationships, and providing a rich and complex assessment of multiple features of attachment. In terms of internal consistency, alpha values were satisfactory and comparable to those found in the original Swiss validation study. Conclusions: Our results are of key importance for both research and clinical work, given the lack of valid and easy-to-administer tools for evaluating adult attachment.

Understanding Appearance-Enhancing Drug Use in Sport Using an Enactive Approach to Body Image

From an enactive approach to human activity, we suggest that the use of appearance-enhancing drugs is better explained by the sense-making related to body image rather than the cognitive evaluation of social norms about appearance and consequent psychopathology-oriented approach. After reviewing the main psychological disorders thought to link body image issues to the use of appearance-enhancing substances, we sketch a flexible, dynamic and embedded account of body image defined as the individual’s propensity to act and experience in specific situations. We show how this enacted body image is a complex process of sense-making that people engage in when they are trying to adapt to specific situations. These adaptations of the enacted body image require effort, perseverance and time, and therefore any substance that accelerates this process appears to be an easy and attractive solution. In this enactive account of body image, we underline that the link between the enacted body image and substance use is also anchored in the history of the body’s previous interactions with the world. This emerges during periods of upheaval and hardship, especially in a context where athletes experience weak participatory sense-making in a sport community. We conclude by suggesting prevention and intervention designs that would promote a safe instrumental use of the body in sports and psychological helping procedures for athletes experiencing difficulties with substances use and body image.

Comorbid drug use disorders and eating disorders — a review of prevalence studies

Aims

This study reviews literature on comorbidity of drug use disorders (DUD) and eating disorders (ED). The article updates knowledge on the occurrence of comorbidity of these diagnoses.

Methods

The databases Embase, Medline and PsycInfo were searched for studies published between 1990 and May 2011, with combinations of the terms ‘eating disorder’, ‘substance-related disorder’, ‘drug dependence’, ‘drug abuse’, ‘drug addiction’ and ‘substance abuse’. This generated altogether 596 studies. Studies in which diagnostic DUD and ED were not assessed in the same sample or the result was not given in percentages were excluded. Thirteen studies remained.

Results

In 11 of the 13 studies, the participants were initially diagnosed with an eating disorder. The prevalence of lifetime drug use disorders varies from 8–43 %. In two studies, DUD is the initial diagnosis, and the participants report 14 % concurrent and 27.3% lifetime ED. The most prevalent co-occurring diagnoses tend to be bulimia nervosa/bingeing-purging anorexia nervosa, and stimulants/cannabis disorders.

Conclusions

The lifetime prevalence percentages of eating disorders in people with drug use disorders (and vice versa) are higher than in the general population. The results indicate that the field of drug disorder treatment and research could benefit from paying closer attention to the risk of eating disorders.

Use of doping agents and symptoms of eating disorders among male and female patients in drug addiction treatment

Aims

This study investigates the prevalence of use of doping agents and symptoms of eating disorders among patients in drug addiction treatment. The aim is also to look for characteristics of the groups reporting the use of doping agents or symptoms of eating disorders.

Design

A survey including questions on exercise, the use of doping agents and Eating Disorder Inventory-2 was administered in a Norwegian drug addiction facility. The study included 109 patients in residential drug treatment, 30 females and 79 males (ranging from 17 to 50 years old).

Results

–Symptoms of eating disorders were reported by 33 percent of the females and 7.6 percent of the males. Previous use of doping agents (anabolic-androgenic steroids in particular) was reported by 40.5 percent of the men and 20 percent of the women. The results are discussed in light of the theory on emotion regulation, gender and cultural expectations, drug treatment as a liminal phase and similarities to drug addiction.

Conclusions

The symptoms of eating disorders and the use of doping agents are prevalent in this sample of male and female drug addicts in treatment. Drug treatment facilities should be aware of this and take the appropriate actions regarding attention, screening and treatment.

Pre-treatment attachment anxiety predicts change in depressive symptoms in women who complete day hospital treatment for anorexia and bulimia nervosa

OBJECTIVES

Individuals with eating disorders are prone to depressive symptoms. This study examines whether depressive symptoms can change in women who complete intensive day treatment for anorexia and bulimia nervosa (BN), and whether these changes are associated with pre-treatment attachment insecurity.

DESIGN

Participants were 141 women with anorexia nervosa restricting type (n = 24), anorexia nervosa binge purge type (n = 30), and BN (n = 87) who completed a day hospital treatment programme for eating disorders. They completed a pre-treatment self-report measure of attachment, and a pre-treatment and post-treatment self-report measure of depressive symptoms.

RESULTS

Participants experienced significant reductions in depressive symptoms at post-treatment. Eating disorder diagnosis was not related to these improvements. However, participants lower in attachment anxiety experienced significantly greater improvement in depressive symptoms than those who were higher in attachment anxiety.

CONCLUSIONS

These results suggest that clinicians may tailor eating disorders treatments to patients' attachment patterns and focus on their pre-occupation with relationships and affect regulation to improve depressive symptoms.

PRACTITIONER POINTS

That depressive symptoms can decrease in women who complete day hospital treatment for anorexia and BN. That improvements in depressive symptoms do not vary according to eating disorder diagnosis in these women. That patients who complete treatment and who have higher attachment anxiety experience less improvements in depressive symptoms compared to those lower in attachment anxiety. That clinicians may attend to aspects of attachment anxiety, such as need for approval and up-regulation of emotions, to improve depressive symptoms in female patients with eating disorders.

Psychological differences between smokers who spontaneously quit during pregnancy and those who do not: a review of observational studies and directions for future research

INTRODUCTION

Although remarkable interindividual differences among pregnant smokers' decision/ability to quit have been documented, the psychological factors that may account for these differences have received less attention and comprised the primary aim of this review.

METHODS

We searched the medical and behavioral sciences literature from 1996 to November 2011 using PubMed and PsycINFO(®). Fifty-one articles were identified based on titles or abstracts. These articles were reviewed in full and searched for quantitative observational studies of population-based or clinical samples, with the main topic of comparing smokers who quit spontaneously during pregnancy with those who did not, utilizing multivariable analyses.

RESULTS

The eight pertinent studies reviewed herein included four longitudinal studies and four cross-sectional analyses. Amidst significant variability among measures used, social support, depressive symptoms, and anxiety appeared unrelated to smoking cessation during pregnancy. Furthermore, when severity of nicotine dependence was controlled, maternal history of attention-deficit/hyperactivity disorder, depression, bipolar disorder, and schizophrenia all showed no independent relationship with smoking cessation during pregnancy, whereas maternal history of conduct disorder did. Secure attachment, prosocial personality, self-esteem, and perceived parenting competence were additional predictors of cessation during pregnancy.

CONCLUSIONS

A greater understanding of psychological factors that differentiate smokers who spontaneously quit during pregnancy from those who do not is crucial to the design of more effective prenatal smoking cessation interventions and also may elucidate causal mechanisms that underlie the well-established link between maternal smoking during pregnancy and offspring behavioral problems. Directions for future research and public health and policy implications are discussed.

Attachment and socio-emotional skills: a comparison of depressed inpatients, institutionalized delinquents and control adolescents

This study compared 50 depressed inpatients, 51 institutionalized delinquents and 51 control adolescents (total n = 152) regarding attachment and associated socio-emotional skills. All of the participants took an individual interview (i.e., anamnesis, diagnostic interview and intelligence test) and completed the attachment measure and self-report measures of socio-emotional skills (i.e., emotional intelligence, empathy and resilience). Results showed that controls scored higher on secure attachment, whereas both of the other groups scored higher on preoccupied attachment. Depressed adolescents had lower scores on emotional intelligence than did controls. Finally, depressed adolescents had lower scores than the other two groups on resilience. The anxious or preoccupied attachment in both clinical groups, the overall frailty of depressive adolescents and the apparent resilience of delinquent adolescents despite their cognitive limitations should inform the respective treatment plans for these groups of adolescents. Suggestions for future research into differences between depressed and delinquent adolescents are outlined.

KEY PRACTITIONER MESSAGE

Both depressed and delinquent adolescents show more anxious attachment. Depressed adolescents are less resilient than delinquent adolescents. Delinquent adolescents are less intelligent than the other two groups but well-adjusted overall. These differences should inform treatment plans for these two clinical groups.

Feelings of insecurity: review of attachment and eating disorders

OBJECTIVE

Attachment theory has received increasing attention from clinicians and researchers in the field of eating disorders. This paper is an updated review on theoretical approaches in the field, and of studies employing the Adult Attachment Interview.

METHOD

We searched the major databases such as PsycInfo and Science Direct for empirical and theoretical studies on attachment and eating disorders, and these are reviewed.

RESULTS

Theoretical approaches on attachment and eating disorders highlight either retrospective, general risk or attachment theoretical statements. There is greater prevalence of insecure attachment in the eating disordered population than in non-clinical samples. However, there is no sufficient evidence to conclude about specific mechanisms for this connection.

DISCUSSION

The theoretical approaches vary in their theoretical grounding, specificity and empirical support. AAI-based research on attachment and eating disorders is still at an early stage. More advanced studies are required for the field to move forward.

Attachment research and eating disorders: a review of the literature

The aim of this article is to review the clinical literature which examines the association between attachment patterns and eating disorders with a focus on anorexia nervosa, and to examine the varieties of methods and measures employed in attachment research. A literature review was carried out and the relevant articles are examined in terms of their contribution to this area. The literature indicates a number of important considerations when working with this group, including extreme separation anxiety and unresolved loss and trauma, and discusses the implications of these findings for treatment. The results also indicate conflicting evidence regarding associations between attachment style and eating disorder subgroup suggesting that severity of disorder matters more than eating disorder subtype. The different ways of investigating attachment patterns and experiences are explored in this paper. It is suggested that the attachment classification system runs the risk of reducing complex human experience to typologies and that qualitative research might help to address this problem.