Attachment style and depression in adults: Using a lifespan model

Antonia BifulcoProfessor of Lifespan Psychology &

Social ScienceKingston University

BPS Conference April 20131

Attachment style and depression in adults: Using a

lifespan model

An Attachment approach(Bowlby, 1969-80 Attachment and Loss trilogy)

04/20/23BPS Conference April 2013

2

Attachment theory is a lifespan approach - childhood experience to adult relationships and disorder.

Attachment style is determined by internal working models - ‘guidance’ system for relationships based on memories of past interactions and expectations of future ones.

Distortion occurs through parental rejection (eg physical abuse), helplessness (eg neglect) or absence (eg separation).

Internal working models determine the type of attachment style in adulthood: those Anxious or Avoidant or Disorganised versus Secure.

As yet there is no consensus about which childhood experiences relate to which style, although all relate to Insecure style in general.

Attachment style assessment is a powerful tool for psychologists


Attachment style is shown to relate to emotional & behavioural disorder (Dozier et al 1999) as part of a bio-psychosocial developmental model (Perry et al 1995).

However, its wider use, particularly in clinical practice, has been hampered by measures which are too superficial (eg RQ, Bartholomew & Horowitz, 1991) or too intensive (AAI,George, Kaplan, Main 1994) and by inconsistency of style definition.

We introduce the Attachment Style Interview as a user-friendly measure to progress research and practice.

Psychosocial model of attachment style and disorder


MajorDepressionor anxiety

onset

Neglect or Abuse <17

Insecure Attachment

Style in adults

Mediating effect

Social factors

Biological factors

Psychological factors

Intensive study of London women

04/20/235

Study aims1.Insecure attachment style will relate to emotional disorder in women2.Childhood neglect/abuse will relate to insecure attachment style.3.Insecure style will act as a mediator4.There will be some specific associations for different attachment styles.Procedure303 London women selected by screening questionnaire from GP lists for high psychosocial risk for depression. Contacted for lengthy face-to-face interview on

childhood experience (CECA)attachment style (ASI)Major Depression and Anxiety disorder. (SCID)

1.154 followed-up 3 years later for onset of depression or anxiety.

04/20/236

Measures - Attachment Style Interview (ASI)

A measure of attachment style in relation to on-going poor supportive contexts.

Three close supportive relationships (partner and Very Close other) questioned about in detail. If one or fewer supportive relationships then poor ability to relate and insecure style rated.

Attitudes towards closeness, trust and autonomy questioned aroundAnxious attitudes (fear of rejection, fear of

separation, desire for company)Avoidant attitudes (mistrust, constraints on

closeness, high self-reliance, anger)Overall attachment styles derived – 4 insecure and

Secure. All insecure styles rated as ‘marked’, ‘moderate’

or ‘mild’ level of insecurity or dysfunction.Good inter-rater reliability (Kappa=0.80 correlation London

study; Kappa=0.70 EU study) 6Bifulco, Moran, Ball & Bernazzani (2002)Adult Attachment Style: Its Relationship to clinical depression, SPPE 37; 50-59

04/20/237

Attachment style classification (ASI)Dual/disorganisedCombined insecure style ratings, usually

Anxious & AvoidantAnxious styles

Enmeshed (low self-reliance, fear of separation, high need for company).

Fearful (mistrust, constraints on closeness; fear rejection)

Avoidant stylesAngry-dismissive (mistrust; self-reliance,

anger)Withdrawn (constraints on closeness; self-

reliance)

SecureCartoons are used in a child version being piloted

Attachment styles relate to survival strategies of fight, flight, cling and hide


Enmeshed styles ‘cling Fearful styles ‘run’

Angry-dismissive styles fight

Withdrawn styles ‘hide’

Secure styles seek help

Measures - Clinical, SCID for DSM-IV

04/20/239

Interview to determine both number and severity of symptoms over the prior 12 months and at follow-up.

DepressionDepressed mood/loss of

interest and four or more key symptoms categorised as cases, together with significant distress/impairment.

Minimum length of episode 4 weeks. The average length proved to be 4 months. Half lasted 12 months or more.

Anxiety disordersGeneralised Anxiety DisorderSocial PhobiaPanic/Agoraphobia

Rates of Disorder35% MDD in year before interview 136% MDD and 40% anxiety at follow-up interview 2:

20% GAD, 10% social phobia, 12% panic/agoraphobia

Childhood Experience of Care and Abuse (CECA)

Bifulco A & Moran P (1998) Wednesday’s Child. Research into women’s experience of neglect and abuse in childhood, and adult depression. Routledge, London10

Interview to determine type and severity of childhood neglect and abuse experiences before age 17.

Factual focus to aid reliability. Probes for timing, sequence and details of experiences.

Lack of care (neglect, antipathy & role reversal)Abuse (physical, psychological & sexual).All experiences rated marked, moderate, mild or

none. Marked/ moderate termed ‘severe’.Index of severe neglect, physical abuse & sexual

abuse derived, 55% of women scored on index.Good inter-rater reliability (above .70). Good

validity determined by sibling accounts

Finding 1 – Attachment style & Depression(N=303, interview 1)

11

% major depression in 12 months

Insecure attachment

Odds-ratio

Wald df P<

Highly Enmeshed 5.83 10.65 1 0.001

Highly Fearful 3.64 8.72 1 0.003

Highly Angry-dismissive

5.01 11.80 1 0.0006

Highly Withdrawn

2.02 1.54 1 NS

Mildly insecure style

1.22 0.30 1 NS

Goodness of fit 78.3%

Controls made for depression at point of interview

Childhood adversity, attachment style and depression

MajorDepression


Highly insecure Attachment

Style*

.28 .32

Childhood adversity index was double in women with insecure style: 58% vs 29%. p<.001

X Neglect/Abuse<17

M –Insecure attachment style*

Y MDD at follow-up

a= 4.53p<.0001

b=2.30p<.00001

c= 1.77, NS

*Withdrawn style excluded

Mediation shown

Attachment style and depression – specificity(Loglinear analysis)

MajorDepression

Highly Enmeshed

Highly Fearful

Highly Angry-dismissive

Highly Withdrawn

.23

.19

.26

ns


.19

.28

ns

ns

Mediation confirmed for Fearful and Angry-dismissive style

Finding 2: Type of attachment style and anxiety disorder in follow-up (N=154)

Attachment style interview 1

Anxiety

disorder

GAD Social Phobia

Panic/Agora

Enmeshed NS NS NS NS

Fearful 0.16* NS 0.21** NS

Angry-dismissive 0.17** 0.18* NS NS

Withdrawn NS NS NS NS

*p< .01, ** ,001, ***.0001

Mediating role of attachment style-Case Anxiety

Case AnxietyFollow-up

Interview 1--------------------Interview 2

Neglect or Abuse in childhood

Highly insecure Attachment

Style*

.33 .33

X Neglect/Abuse<17

M – Insecure attachmentstyle

Y Case AnxietyF-u

a= 4.53p<.0001

b=3.28p<.00001

c= 1.367, NS

Mediation confirmed

*Withdrawn style excluded

Antipathy

Neglect

Role reversal

Physical

Sexual

Psychological

Enmeshed

Fearful

Angry-dismissive

Withdrawn

.15*

.20**

.19**

.14*

.17*

.12*

.12*

.14*

* p<.05, ** p<.01

CECA ASI styles

Lack of Care

Abuse

Specificity - childhood experience and attachment style

Severe Lack of care(Antipathy or Neglect

Or Role Reversal

Severe Abuse(Physical, Sexual or

Psychological)

Anxious style(Enmeshed or

Fearful)

Angry-Dismissivestyle

OR=4.19*

OR=4.51*

OR= significant odds ratios taken from binary logistic regression analyses. *p<.05

ASICECA

Bifulco & Thomas (2012) Understanding adult attachment in family relationships: Research, Assessment, Intervention. Routledge, London.

Childhood experiences and style – regression analyses

Implications

04/20/2318

Insecure attachment style mediates the relationship between early adverse experience and adult major depression and anxiety. Some specificity of style to experience and disorder is shown.

Early intervention in childhood to protect against neglect/abuse or in early adulthood to ameliorate attachment style can reduce disorder in adult life.

Improving the quality of adult relationships and support can reduce attachment insecurity.

Clinical psychologists, CAMHS and perinatal psychologists can benefit from assessing attachment style in clients or their parents.

The ASI as a research-based assessment tool is available for practice contexts to utilise this evidence-base in child and family social services and psychological services to aid best practice.

[email protected]


Thank you for your attention

Attachment style and depression in adults: Using a lifespan model

Documents

Transcript of Attachment style and depression in adults: Using a lifespan model