Publications by authors named "Anna Buchheim"

76 Publications

The Stress of Caring-Resilience and HPA-Axis Activity in Hair Samples of Youth Residential Caregivers.

Front Psychiatry 2020 21;11:556486. Epub 2020 Dec 21.

Child and Adolescent Psychiatric Research Department, University Psychiatric Hospitals, University of Basel, Basel, Switzerland.

Professional caregivers in youth residential care institutions experience frequent verbal and physical aggression as well as multiple stressors as part of their everyday work, leading to high levels of burnout and staff turnover. Resilience might buffer against psychophysiological stress response and therefore be crucial for well-being in professional caregivers. We aimed to investigate if measures related to resilience [sense of coherence (SoC), self-efficacy and self-care] and attachment security of caregivers were cross-sectionally associated with stress markers in hair samples [cortisol and dehydroepiandrosterone (DHEA)]. Participants ( = 134; 64.2% women) reported on individual resilience measures and provided hair samples for cortisol and DHEA assays. Attachment was assessed in a subsample using the Adult Attachment Projective Picture System (AAP, = 69). Linear regression models were fitted to estimate the association between resilience measures and the Cortisol:DHEA ratio, cortisol and DHEA, controlling for gender and age. SoC was associated with a lower Cortisol:DHEA ratio (β = -0.36, < 0.001), driven by a positive association between SoC and DHEA levels (β = 0.28, = 0.002). Self-care was also associated with lower Cortisol:DHEA ratios (β = -0.24, = 0.005), due to self-care being associated with higher DHEA (β = 0.21, = 0.016). HPA-axis measures were not associated with self-efficacy nor with attachment patterns in a subsample. Our findings imply that youth residential care institutions might benefit from programs focusing on enhancing SoC and self-care practices. Fostering a meaningful, comprehensible and manageable professional climate in caregiving environments and implementing self-care in routine practices might enhance not only well-being but also physical health of professional caregivers and in this way buffer adverse health effects of chronic stressors.
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http://dx.doi.org/10.3389/fpsyt.2020.556486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7779549PMC
December 2020

Insecure and Unresolved/Disorganized Attachment in Patients With Psychogenic Nonepileptic Seizures.

J Acad Consult Liaison Psychiatry 2021 May-Jun;62(3):337-344. Epub 2020 May 25.

Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt- Universität zu Berlin, and Berlin Institute of Health, Department of Psychosomatic Medicine, Berlin, Germany.

Background: Psychogenic nonepileptic seizures (PNES) are still poorly understood and difficult to treat. Attachment theory could add new aspects to the understanding of the multifactorial genesis and maintenance of PNES and the therapeutic needs of this patient group.

Objective: The aim of the present study is to systematically assess attachment in adult patients with PNES with a focus on the role of unresolved/disorganized attachment.

Methods: A cross-sectional design was chosen to compare patients with confirmed PNES (n = 44) and healthy controls (n = 44) matched for gender, age, and education. Attachment was assessed using the Adult Attachment Projective Picture System. Psychometric questionnaires included the Childhood Trauma Questionnaire; Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) axis II disorders, Patient Questionnaire; the Somatoform Dissociation Questionnaire; and the Patient Health Questionnaire.

Results: We found significantly less secure (P = 0.006) and more unresolved/disorganized (P = 0.041) attachment classifications in the PNES group. Among patients with PNES, 7% were classified secure and 43% were classified unresolved/disorganized. Patients with an unresolved attachment representation were significantly more likely to be screened positive for personality pathology in the Structured Clinical Interview for DSM-IV axis II disorders, Patient Questionnaire (P = 0.03) and to report more emotional abuse in the Childhood Trauma Questionnaire (P = 0.007) than patients with other attachment classifications.

Conclusions: Our findings suggest that unresolved/disorganized attachment might be the predominant attachment style in patients with PNES and might be associated with more severe personality pathology. This could be of therapeutic relevance. The present study is the first to assess adult attachment in patients with PNES using a semi-structured interview in comparison to matched healthy controls.
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http://dx.doi.org/10.1016/j.psym.2020.05.014DOI Listing
May 2020

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

Front Psychiatry 2020 25;11:460506. Epub 2020 Sep 25.

Department of Psychiatry and Psychotherapeutic Medicine, Medical University Graz, Graz, Austria.

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.
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http://dx.doi.org/10.3389/fpsyt.2020.460506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7544992PMC
September 2020

Unresolved Attachment Mediates the Relationship Between Childhood Trauma and Impaired Personality Functioning in Adolescence.

J Pers Disord 2020 Sep 28;34(Supplement B):84-103. Epub 2020 Jan 28.

Department of Child and Adolescent Psychiatry, Psychiatric University Clinics, Basel, Switzerland.

The present study investigates the mediating effect of attachment trauma on the relationship between childhood maltreatment and personality functioning in 199 adolescents (12-18 years) using a novel approach of an in-depth analysis of attachment-related traumatic contents during an attachment interview (AAP). Our findings demonstrate that adolescents with a high amount of traumatic attachment-related material show a lower resilience when facing traumatic childhood experiences, resulting in a greater severity of personality dysfunction. In particular, the associations between emotional abuse and neglect and the domains of identity, empathy, self-direction, and intimacy were mediated by the severity of attachment trauma. These results advance our understanding of the different nuances of attachment-related traumatic material and how they might shape personality structure in an adolescent age group.
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http://dx.doi.org/10.1521/pedi_2020_34_468DOI Listing
September 2020

A Bifactor Model of Personality Organization.

J Pers Assess 2021 Mar-Apr;103(2):149-160. Epub 2020 Jan 9.

Department of Psychology, University of Kassel, Germany.

The aim of this study was to explore the viability of a bifactor model for the Inventory of Personality Organization (IPO), which is a self-report measure of personality functioning based on Kernberg's model of personality organization. A heterogeneous, predominantly clinical sample ( = 616) completed the German 83-item version of the IPO. Confirmatory and Exploratory Factor Analyses were applied to explore the factor structure of the IPO. We were able to establish a bifactor model with a general factor of personality functioning and three specific factors (Aggression, Reality Testing, Moral Values), which represent additional dimensions of personality organization. Virtually all items showed substantial positive loadings on the general factor, explaining roughly 66% of the common variance. Furthermore, we found support for convergent and discriminant validity of general and specific factors with regard to interview-based assessments of personality disorders and personality organization. The results lend support to a bifactor approach to Kernberg's model of personality organization. We also present a 30-item brief form of the IPO that efficiently implements the bifactor approach and may be further validated in future studies.
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http://dx.doi.org/10.1080/00223891.2019.1705463DOI Listing
June 2021

Attachment-specific speech patterns induce dysphoric mood changes in the listener as a function of individual differences in attachment characteristics and psychopathology.

Psychol Psychother 2020 12 20;93(4):754-776. Epub 2019 Nov 20.

Clinical Affective Neuroimaging Laboratory, Magdeburg, Germany.

Objectives: Early childhood experiences influence cognitive-emotional development, with insecure attachment predisposing to potential psychopathologies. We investigated whether narratives containing attachment-specific speech patterns shape listeners' emotional responses and social intentions.

Design: First, 149 healthy participants listened to three narratives characteristic for secure, insecure-preoccupied, and insecure-dismissing attachment. Following each narrative, the well-being and interpersonal reactivity as a particular aspect of emotional reactivity of the listener were assessed. Likewise, psychopathological aspects of personality were evaluated. A follow-up study compared 10 psychosomatic patients with a current depressive episode and/or personality disorder with distinct depressive symptoms and 10 age- and gender-matched healthy controls.

Methods: Effects of narratives on listeners' mental state were tested with repeated-measures AN(C)OVA. Mediating effects in the listener (attachment characteristics in the context of personality traits) were explored. Narrative effects were compared between patients and controls.

Results: Listening to insecure attachment narratives reduced well-being in controls. Nevertheless, tendency for social interaction was highest following the insecure-preoccupied narrative. Importantly, listeners' individual attachment characteristics mediated the relationship between well-being/interpersonal reactivity following the insecure-preoccupied narrative and levels of psychopathology. Furthermore, compared with healthy participants, patients showed higher emotional reactivity following exposure to the insecure-preoccupied narrative, represented by lower well-being and lower estimation of friendliness towards the narrator.

Conclusions: Exposure to attachment-specific speech patterns can result in dysphoric mood changes. Specifically, the insecure-preoccupied narrative influenced the listeners' emotional state, which was further mediated by the individual attachment patterns and psychopathological personality characteristics. This deepens the understanding of interpersonal processes, especially in psychotherapeutic settings.

Practitioner Points: In clinical populations, insecure-preoccupied attachment has a high prevalence. In this study, listening to a narrative characteristic of insecure-preoccupied speech patterns resulted in reduced well-being in healthy listeners. Patients with depressive symptoms showed a higher emotional reactivity towards the insecure-preoccupied narrative compared to healthy controls. While working on (childhood) traumata, for example, in group therapy or inpatient settings, therapists should raise awareness to possible mood changes through discourse-conveyed attachment characteristics in listeners as a 'side effect'.
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http://dx.doi.org/10.1111/papt.12258DOI Listing
December 2020

Reduced caregiving quality measured during the strange situation procedure increases child's autonomic nervous system stress response.

Child Adolesc Psychiatry Ment Health 2019 31;13:41. Epub 2019 Oct 31.

2Department of Psychosomatic Medicine and Psychotherapy, University Hospital of Ulm, Ulm, Germany.

Background: Dysfunctional maternal behavior has been shown to lead to disturbances in infant's regulatory capacities and alterations in vagal reactivity. We aim to investigate the autonomic nervous system (ANS) response of the child during the strange situation procedure (SSP) in relation to the quality of maternal behavior.

Methods: Twelve month after birth, 163 mother-child-dyads were investigated during the SSP. Heart rate (HR) and both, the parasympathetic branch (PNS) via the respiratory sinus arrhythmia (RSA) and the sympathetic branch (SNS) via the left ventricular ejection time (LVET) of the ANS were continuously determined during the SSP using electrocardiogram (ECG) and impedance cardiogram (ICG) measures. Maternal behavior was assessed by using the AMBIANCE measure.

Results: The ANS response in infants of mothers with disruptive behavior compared to infants of non-disruptive mothers was significantly altered during the SSP: HR increased especially when infants of disruptive mothers were alone with the stranger (F (1, 161) = 4.15, p = .04) with a significant vagal withdrawal when being in contact with the stranger despite of presence of the mother (F (1, 161) = 5.11, p = .03) and a significant increase in vagal tone during final reunion (F (1, 161) = 3.76, p = .05). HR increase was mainly based on a decrease in LVET (F (1, 161) = 4.08, p = .05) with a maximum infant's HR when the stranger came into the room instead of the mother.

Conclusion: Both, SNS and PNS branches of the child are significantly altered in terms of an ANS imbalance, especially during contract to a stranger, in relation to dysfunctional maternal behavior. Our findings suggest the importance of supporting high quality caregiving that enables the infant to adapt adequately to stressful interpersonal situations which is likely to promote later health.
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http://dx.doi.org/10.1186/s13034-019-0302-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824052PMC
October 2019

[Differences in Conflict-Based Play Behavior, Socio-Emotional and Cognitive Development of Preterm Children Compared to Full-Term Children at Preschool Age].

Prax Kinderpsychol Kinderpsychiatr 2019 Sep;68(6):503-524

Univ.-Klinik für Pädiatrie II Innsbruck Österreich Univ.-Klinik für Pädiatrie II Innsbruck.

Preterm children are at increased risk for socio-emotional and cognitive developmental difficulties at preschool age. This study investigates whether preterm children (n = 50) at the age of five years show different socio-emotional competencies in conflict situations and in the corresponding conflict resolution capacity in comparison to full-term children (n = 50). For this purpose, the MacArthur Story Stem Battery was used as the central examination method. In addition, parents completed the Strengths and Difficulties Questionnaire to obtain information about the children's behavior; moreover, the Wechsler Preschool and Primary Scale of Intelligence - Third Edition was applied to examine cognitive development. The parental reports did not reveal any behavioral differences between preterm and term children. However, significant group differences regarding their play behavior were detected. In their narratives, preterm children included content themes of interpersonal conflict and dysregulation more frequently compared to term born controls. Concerning empathic and moral themes and narrative coherence, no group difference could be detected. This could indicate that preterm children show no clinically manifest behavioral disorders at preschool age, but differences concerning intrapsychic experience compared to controls. In addition, preterm children had significantly lower IQ scores than term-born controls. Gestational age was a significant predictor of IQ and hyperactivity and attention problems. The results clarify the need for long term clinical follow up of preterm children and should be used to provide more specific care and support.
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http://dx.doi.org/10.13109/prkk.2019.68.6.503DOI Listing
September 2019

Mirror neuron activations in encoding of psychic pain in borderline personality disorder.

Neuroimage Clin 2019 28;22:101737. Epub 2019 Feb 28.

Department of Psychiatry and Psychotherapy III, University of Ulm, Ulm, Germany; Institute of Psychology, University of Innsbruck, Innsbruck, Austria. Electronic address:

Borderline personality disorder (BPD) is characterized by pronounced emotional instability in interpersonal relations. Previous studies have shown increased activity in the amygdala, an imaging phenotype of negative affect. However, clinical accounts of BPD have drawn attention to deficits in social cognition and their likely role in engendering emotional instability. BPD patients show enhanced sensitivity to other people's emotions, while being less proficient in reading motives and reasons. In the present functional imaging study, we exposed BPD participants to stylized scenes of individuals affected by loss or separation, an issue to which these patients are particularly sensitive. Previously shown to activate the mirror neuron system, these mourning scenes were here also used to assess differential amygdala activity in stimuli of negative valence, but low arousal. Relative to controls, BPD patients were found to activate sensorimotor areas, a part of the mirror neuron system thought to encode basic aspects of the perception of motoric activity and pain. This contrasted with the activity of areas related to more complex aspects of social cognition, such as the inferior frontal gyrus. The amygdala was more active in patients when viewing these scenes, but this effect also showed a strong association with levels of depressiveness and neuroticism. After adjusting for these covariates, differences in amygdala activation were no longer significant. These findings are consistent with models of social cognition in BPD that attribute emotional sensitivity to emotional contagion through the mirror neuron system, in contrast to areas associated with more sophisticated forms of social cognition. These effects were accompanied by increased amygdala reactivity, consistently with the common occurrence of affective symptoms in these patients.
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http://dx.doi.org/10.1016/j.nicl.2019.101737DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6402375PMC
December 2019

The role of attachment characteristics in dialectical behavior therapy for patients with borderline personality disorder.

Clin Psychol Psychother 2019 May 22;26(3):339-349. Epub 2019 Feb 22.

Department of Psychology, University of Innsbruck, Innsbruck, Austria.

Attachment characteristics play a key role in understanding borderline-specific problems with respect to childhood maltreatment. The aim of this study was to investigate how attachment representations may influence the trajectory of change in a 1-year outpatient dialectical behavior therapy (DBT) for patients with borderline personality disorder (BPD). Attachment representations were assessed in 26 BPD patients and 26 healthy controls (HC) using the Adult Attachment Projective Picture System (AAP) before treatment. Borderline and global symptom severity and interpersonal problems were examined before, during, and after completing the intervention. Analysis of variance and stepwise hierarchical regression analyses were used to explore the course of symptomatology. As expected, BPD patients displayed a predominance of unresolved attachment in the AAP compared with HC, by showing a lack of ability to integrate attachment related trauma. Whereas both resolved and unresolved attachment groups revealed significant improvement in symptom severity during treatment, dimensional AAP scores showed differences. Patients with higher scores in "synchrony" demonstrated more indicators of mutual care in their narratives to dyadic pictures and displayed a significantly stronger decrease of interpersonal problems than patients with lower synchrony scores. Assessing attachment representations prior to DBT might provide a helpful insight into individual attachment related resources or lack of these capacities. Responsiveness and synchrony in dyadic interactions with significant others are crucial for healthy interpersonal relations. A stronger therapeutic focus on the patient's capacity to show synchrony in dyadic attachment situations might improve the patient's interpersonal problems towards sensitive and mutual interaction.
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http://dx.doi.org/10.1002/cpp.2355DOI Listing
May 2019

Changes in Attachment Representation in Psychotherapy: Is Reflective Functioning the Crucial Factor?

Z Psychosom Med Psychother 2018 09;64(3):222-236

Institute of Psychology University of Innsbruck Austria Institute of Psychology, University of Innsbruck.

Objectives: The study analyzed the interdependence of change in attachment representation and reflective functioning (RF) in psychotherapy.

Methods: RF data from 63 female borderline personality disorder (BPD) patients were analyzed with respect to change of attachment representation (from insecure to secure and from unresolved to resolved) fromthree angles: (1) RF as a moderator variable, (2) RF as an outcome variable, and (3) RF changes over one year of treatment.

Results: Patients who changed to a resolved attachment classification showed higher RF before treatment and at follow-up than patients who remained unresolved (RF = 3.0 vs. RF = 2.14, p = 0.039; and RF = 3.4 vs. RF = 2.36, p = 0.002). Similar results were found for changes from insecure to secure.

Conclusion: A higher RF level before psychotherapy proved to be a moderator for change in attachment representation. Patients with unresolved attachment and low-level RF at the outset had the least chance for representational change during the first year of psychotherapy.
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http://dx.doi.org/10.13109/zptm.2018.64.3.222DOI Listing
September 2018

Attachment and Borderline Personality Disorder.

Psychiatr Clin North Am 2018 12;41(4):651-668

City University of New York, Personality Disorders Institute, Weill Medical Center of Cornell University, New York University, New York, NY, USA.

Borderline personality disorder is associated with predominant insecure and unresolved attachment representations, linked history of trauma, impaired cognitive functioning and oxytocin levels, and higher limbic activations. Two randomized clinical trials on transference-focused psychotherapy assessed change of attachment representation and reflective functioning. The first showed that transference-focused psychotherapy was superior, demonstrating significant improvements toward attachment security and higher reflective functioning. The second randomized clinical trial study on transference-focused psychotherapy compared with therapy as usual replicated these results and additionally showed a significant shift from unresolved to organized attachment in the transference-focused psychotherapy group only, suggesting its effectiveness in traumatized patients.
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http://dx.doi.org/10.1016/j.psc.2018.07.010DOI Listing
December 2018

Disorder-specific attachment characteristics and experiences of childhood abuse and neglect in adolescents with anorexia nervosa and a major depressive episode.

Clin Psychol Psychother 2018 Nov 14;25(6):894-906. Epub 2018 Sep 14.

Institute of Psychology, University of Innsbruck, Innsbruck, Austria.

For the first time, the present study investigates disorder-specific attachment characteristics and childhood trauma in adolescent inpatients with anorexia nervosa (n = 30, girls/boys: 28/2, age: M = 14.84, SD = 1.20), a major depressive episode (n = 30, girls/boys: 27/3, age: M = 15.14, SD = 1.50), and controls (n = 60, girls/boys: 44/16, age: M = 16.10, SD = 1.20). We used the Structured Clinical Interview to diagnose Axis I disorders, the Adult Attachment Projective Picture System to classify attachment representations, and the Childhood Trauma Questionnaire to assess child maltreatment. Our findings demonstrate an overrepresentation of the unresolved attachment status in the patient samples. A one-way analysis of variance succeeded by Bonferroni post hoc tests indicated that adolescents with anorexia nervosa show more isolation and dissolution of boundaries between life and death when confronted with situations of solitude. Although they report moderate to severe levels of traumatic childhood experiences, they tend to minimize those. Adolescents with a major depressive episode report higher levels of emotional abuse and neglect in their childhood, leaving them in a state of failed protection and danger during attachment distress. Integrating these attachment-related characteristics into specific psychotherapeutic interventions might be associated with a better outcome in that age group.
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http://dx.doi.org/10.1002/cpp.2324DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6585713PMC
November 2018

Exposure to attachment narratives dynamically modulates cortical arousal during the resting state in the listener.

Brain Behav 2018 07 6;8(7):e01007. Epub 2018 Jun 6.

Clinical Affective Neuroimaging Laboratory, Magdeburg, Germany.

Background: Affective stimulation entails changes in brain network patterns at rest, but it is unknown whether exogenous emotional stimulation has a prolonged effect on the temporal dynamics of endogenous cortical arousal. We therefore investigated differences in cortical arousal in the listener following stimulation with different attachment-related narratives.

Methods: Resting-state EEG was recorded from sixteen healthy subjects for ten minutes each with eyes closed: first at baseline and then after passively listening to three affective narratives from strangers about their early childhood experiences (prototypical for insecure-dismissing, insecure-preoccupied, and secure attachment). Using the VIGALL 2.1 algorithm, low or high vigilance stages in consecutive EEG segments were classified, and their dynamic profile was analyzed. Questionnaires assessed the listeners' emotional response to the content of the narrative.

Results: As a general effect of preceding affective stimulation, vigilance following the stimulation was significantly elevated compared to baseline rest, and carryover effects in dynamic vigilance profiles were observed. A difference between narrative conditions was revealed for the insecure-dismissing condition, in which the decrease in duration of high vigilance stages was fastest compared to the other two conditions. The behavioral data supported the observation that especially the insecure narratives induced a tendency in the listener to affectively disengage from the narrative content.

Discussion: This study revealed carryover effects in endogenous cortical arousal evoked by preceding affective stimulation and provides evidence for attachment-specific dynamic alterations of brain states and individual differences in emotional reactivity.
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http://dx.doi.org/10.1002/brb3.1007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6043700PMC
July 2018

Emotional neglect in childhood shapes social dysfunctioning in adults by influencing the oxytocin and the attachment system: Results from a population-based study.

Int J Psychophysiol 2019 02 1;136:73-80. Epub 2018 Jun 1.

Institute of Psychology, University of Innsbruck, Innrain 52f, 6020 Innsbruck, Austria.

Early life maltreatment (ELM) is the major single risk factor for impairments in social functioning and mental health in adulthood. One of the most prevalent and most rapidly increasing forms of ELM is emotional neglect. According to bio-behavioral synchrony assumptions, the oxytocin and attachment systems play an important mediating role in the interplay between emotional neglect and social dysfunctioning. Therefore, the aim of the present study was to investigate whether fear and avoidance of social functioning, two important and highly prevalent facets of social dysfunctioning in adulthood, are shaped by emotional neglect, plasma oxytocin levels and attachment representations. We assessed emotional neglect as well as other forms of ELM with the Childhood Trauma Questionnaire, current attachment representations with the Adult Attachment Projective Picture System, and fear and avoidance of social situations with the Liebowitz Social Anxiety Scale in a population-based sample of N = 121 men and women. Furthermore, 4.9 ml blood samples were drawn from each participant to assess peripheral plasma oxytocin levels. Applying a sequential mediation model, results revealed that emotional neglect was associated with lower plasma oxytocin levels which in turn were associated with insecure attachment representations which were related to elevated fear and avoidance of social situations (adb: F = 20.84, P < .001). Plasma oxytocin and current attachment representations hence fully and sequentially mediate the effects of emotional neglect on social fear and avoidance, two important facets of adult social dysfunctioning, confirming bio-behavioral synchrony assumptions.
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http://dx.doi.org/10.1016/j.ijpsycho.2018.05.011DOI Listing
February 2019

Modulation of Gamma Band Activity and Late Positive Potential in Patients with Chronic Depression after Psychodynamic Psychotherapy.

Psychother Psychosom 2018 16;87(4):252-254. Epub 2018 May 16.

Department of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Munich, Germany.

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http://dx.doi.org/10.1159/000488090DOI Listing
November 2018

[Attachment Based Short Intervention During Inpatient Treatment of Adolescents].

Prax Kinderpsychol Kinderpsychiatr 2018 May;67(4):367-385

Leopold-Franzens-Universität Innsbruck Institut für Psychologie Innrain 52 A-6020 Innsbruck Österreich Institut für Psychologie - Universität Innsbruck.

Attachment Based Short Intervention During Inpatient Treatment of Adolescents In clinical attachment research the established and economic Adult Attachment Projective Picture System (AAP) has been increasingly used in the past few years to assess the attachment representations in adults and recent studies demonstrated sufficient validity for assessing attachment representations in adolescents. Apart from coding attachment classifications, the AAP provides useful and clinically valid information concerning attachment related defences, aspects of capacity to act and synchrony in relationships and emotion regulation strategies with respect to attachment related traumatic experiences. These valuable aspects with respect to individual resources led to the conceptualization to implement the AAP in the therapeutic setting as a feedback tool. In this pilot case we report on an adolescent patient in an inpatient setting. The therapist received an individualized feedback on the patients' AAP to focus on specific attachment related themes used as a short intervention respective an add-on treatment. This paper presents the first results of this new approach by demonstrating the potential therapeutic effects and process of therapy.
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http://dx.doi.org/10.13109/prkk.2018.67.4.367DOI Listing
May 2018

Use of the Adult Attachment Projective Picture System in the formulation of a case of an adolescent refugee with PTSD.

J Trauma Dissociation 2018 Oct-Dec;19(5):572-595. Epub 2018 Mar 16.

a Department of Child and Adolescent Psychiatry , Medical University of Innsbruck , Innsbruck, Austria.

Forced displacements and their psychosocial consequences in adolescent refugees and their families have received increasing attention in recent years. Although supportive family relations play a key role in buffering the impact of traumatization in adolescents, parental ability to provide such is often subject to extreme pressure. Under conditions of forced dislocation and fear, maladaptive interpersonal strategies in the parent-child relationships may develop, contributing to the onset of psychopathology. We explore new aspects of attachment-related issues for the understanding and treatment of adolescent refugees who have experienced multiple traumas in their childhood. We used a multimethod assessment battery including the Adult Attachment Projective Picture System (AAP), the Structured Clinical Interview, the Youth Self Report and the Wechsler Intelligence Scale in an adolescent boy with post-traumatic stress disorder (PTSD). Our subject was an adolescent refugee from the Middle East who demonstrated an unresolved attachment when confronted with loss and fear. His responses on the AAP evoked aspects of insecure-unresolved attachment, including his belief that it is not safe to trust in attachment figures, his limited access to traumatic attachment experiences, his impaired ability to take concrete actions when dealing with threatening attachment situations and the unintentional role-reversal shed new light on our understanding of his traumatic experiences, family functioning and psychopathological symptoms. Our results demonstrate the utility of the AAP in an adolescent refugee with PTSD by expanding our knowledge of a diverse range of experiences across the interpersonal, cognitive, cultural and developmental contexts that formed the basis for an individualized treatment plan.
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http://dx.doi.org/10.1080/15299732.2018.1451803DOI Listing
March 2019

Child Maltreatment Is Associated with a Reduction of the Oxytocin Receptor in Peripheral Blood Mononuclear Cells.

Front Psychol 2018 27;9:173. Epub 2018 Feb 27.

Department of Psychosomatic Medicine and Psychotherapy, Ulm University, Ulm, Germany.

Child maltreatment (CM) and attachment experiences are closely linked to alterations in the human oxytocin (OXT) system. However, human data about oxytocin receptor (OXTR) protein levels are lacking. Therefore, we investigated oxytocin receptor (OXTR) protein levels in circulating immune cells and related them to circulating levels of OXT in peripheral blood. We hypothesized reduced OXTR protein levels, associated with both, experiences of CM and an insecure attachment representation. OXTR protein expressions were analyzed by western blot analyses in peripheral blood mononuclear cells (PBMC) and plasma OXT levels were determined by radioimmunoassay (RIA) in 49 mothers. We used the Childhood Trauma Questionnaire (CTQ) to assess adverse childhood experiences. Attachment representations (secure vs. insecure) were classified using the Adult Attachment Projective Picture System (AAP) and levels of anxiety and depression were assessed with the German version of the Hospital Depression and Anxiety scale (HADS-D). CM-affected women showed significantly lower OXTR protein expression with significantly negative correlations between the OXTR protein expression and the CTQ sum score, whereas plasma OXT levels showed no significant differences in association with CM. Lower OXTR protein expression in PBMC were particularly pronounced in the group of insecurely attached mothers compared to the securely attached group. Anxiety levels were significantly higher in CM-affected women. This study demonstrated a significant association between CM and an alteration of OXTR protein expression in human blood cells as a sign for chronic, long-lasting alterations in this attachment-related neurobiological system.
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http://dx.doi.org/10.3389/fpsyg.2018.00173DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5835067PMC
February 2018

Facial Behavior During an Attachment Interview in Patients With Complicated Grief.

J Nerv Ment Dis 2018 05;206(5):340-349

The present study investigated differences in various aspects of facial behavior among female patients with complicated grief (CG; n = 18) and healthy controls (n = 18) during the assessment of their attachment representation using the Adult Attachment Projective Picture System. All patients were classified with an unresolved attachment status. On a behavioral level, they demonstrated longer gazing behavior away from the interviewer and the picture stimuli, more speech pauses, less smiling toward the interviewer, and more crying, especially in response to stimuli portraying the theme of loss. Focusing on the in-depth analysis of death-related stimuli using the Facial Action Coding System, patients demonstrated less facial affective behavior, less disgust, and less smiling in response to these stimuli compared with the healthy controls. The impaired capacity of patients with CG responding in an affective appropriate manner regarding bereavement might be interpreted as a specific emotion dysregulation when their attachment and mourning system is activated.
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http://dx.doi.org/10.1097/NMD.0000000000000800DOI Listing
May 2018

The iconography of mourning and its neural correlates: a functional neuroimaging study.

Soc Cogn Affect Neurosci 2017 08;12(8):1303-1313

Institute of Psychology, University of Innsbruck, Tyrol, Austria.

The present functional neuroimaging study focuses on the iconography of mourning. A culture-specific pattern of body postures of mourning individuals, mostly suggesting withdrawal, emerged from a survey of visual material. When used in different combinations in stylized drawings in our neuroimaging study, this material activated cortical areas commonly seen in studies of social cognition (temporo-parietal junction, superior temporal gyrus, and inferior temporal lobe), empathy for pain (somatosensory cortex), and loss (precuneus, middle/posterior cingular gyrus). This pattern of activation developed over time. While in the early phases of exposure lower association areas, such as the extrastriate body area, were active, in the late phases activation in parietal and temporal association areas and the prefrontal cortex was more prominent. These findings are consistent with the conventional and contextual character of iconographic material, and further differentiate it from emotionally negatively valenced and high-arousing stimuli. In future studies, this neuroimaging assay may be useful in characterizing interpretive appraisal of material of negative emotional valence.
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http://dx.doi.org/10.1093/scan/nsx058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5597887PMC
August 2017

Editorial: Neuroscience of Human Attachment.

Front Hum Neurosci 2017 24;11:136. Epub 2017 Mar 24.

Institute of Psychology, University of Innsbruck Innsbruck, Austria.

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http://dx.doi.org/10.3389/fnhum.2017.00136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5364168PMC
March 2017

Effects of the Adult Attachment Projective Picture System on Oxytocin and Cortisol Blood Levels in Mothers.

Front Hum Neurosci 2016 8;10:627. Epub 2016 Dec 8.

Institute of Psychology, University of Innsbruck Innsbruck, Austria.

Oxytocin, a small neuropeptide of nine amino acids, has been characterized as the "hormone of affiliation" and is stimulated, for instance, in mothers when interacting with their offspring. Variations in maternal oxytocin levels were reported to predict differences in the quality of care provided by mothers. In this study, the Adult Attachment Projective Picture System (AAP) as a valid measure to assess attachment representations was used as an activating attachment-related stimulus. We investigated whether the AAP induces a release of oxytocin in mothers with a secure attachment representation and a stress-related cortisol response in mothers with an insecure attachment representation. Therefore, pre-post effects of AAP administration on plasma oxytocin and serum cortisol levels were investigated in = 44 mothers 3 months after parturition. Oxytocin levels increased from pre to post in the significant majority of 73% participants ( = 0.004) and cortisol decreased in the significant majority of 73% participants ( = 0.004). Interestingly, no association between alterations in oxytocin and cortisol were found; this suggests taking a model of two independent processes into considerations. These results show that the AAP test procedure induces an oxytocin response. Concerning the results within the four AAP representation subgroups, our hypothesis of a particularly strong increase in oxytocin in secure mothers was not confirmed; however, in secure mothers we observed a particularly strong decrease in cortisol. Effect sizes are reported, allowing the replication of results in a larger study with sufficient sample size to draw final conclusions with respect to differences in OT and cortisol alterations depending on attachment representation. When interpreting the results, one should keep in mind that this study investigated lactating mothers. Thus, the generalizability of results is limited and future studies should investigate non-lactating healthy females as well as males and include a control stimulus condition.
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http://dx.doi.org/10.3389/fnhum.2016.00627DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5143683PMC
December 2016

Exploring the effectiveness of combined mentalization-based group therapy and dialectical behaviour therapy for inpatients with borderline personality disorder - A pilot study.

Br J Clin Psychol 2017 Mar 29;56(1):1-15. Epub 2016 Nov 29.

Department of Psychiatry, Psychotherapy and Preventive Medicine, Ruhr-University Bochum, LWL University Hospital Bochum, Germany.

Objectives: Borderline personality disorder (BPD) is characterized by emotional instability, interpersonal dysfunction, and other features that typically develop before a background of insecure attachment and traumatic experiences. Dialectical behaviour therapy (DBT) has proven highly effective in reducing self-harm and improving emotion regulation, whereby problems concerning social cognition, which are also characteristic of BPD, may need additional approaches such as mentalization-based treatment (MBT).

Methods: Here, we examined, in a pilot study, the effectiveness of MBT given adjunct to DBT, compared to DBT alone, in an inpatient sample with BPD, whereby mentalization was measured using a novel cartoon-based task.

Results: Both treatments were highly effective in reducing symptom severity. The combination of DBT and MBT was superior in reducing fearful attachment and in improving affective mentalizing.

Conclusions: Mentalization-based treatment in combination with DBT may improve certain aspects of social cognitive skills and attachment security, as compared to DBT alone, although the exact mechanisms that led to these changes need to be studied further.

Practitioner Points: Clinical implications Dialectical behaviour therapy (DBT) can usefully be combined with mentalization-based treatment (MBT). The combination of DBT and MBT reduces self-harm more than DBT alone. DBT plus MBT may lead to a reduction in fearful attachment and improvement of affective mentalizing. Short-term combinations of evidence-based borderline treatments may enrich psychiatric inpatient care. Therefore, such approaches deserve further research. Limitations The treatment condition was therapeutically more intense than the control condition. The study lacked a follow-up assessment. The impact of comorbid conditions on treatment response was not taken into account. Adherence to the manualized approach was not measured.
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http://dx.doi.org/10.1111/bjc.12123DOI Listing
March 2017

A Reaction Time Experiment on Adult Attachment: The Development of a Measure for Neurophysiological Settings.

Front Hum Neurosci 2016 2;10:548. Epub 2016 Nov 2.

Department of Psychosomatic Medicine and Psychotherapy, Ulm University Ulm, Germany.

In the last few decades, there has been an increase of experimental research on automatic unconscious processes concerning the evaluation of the self and others. Previous research investigated implicit aspects of romantic attachment using self-report measures as explicit instruments for assessing attachment style. There is a lack of experimental procedures feasible for neurobiological settings. We developed a reaction time (RT) experiment using a narrative attachment measure with an implicit nature and were interested to capture automatic processes, when the individuals' attachment system is activated. We aimed to combine attachment methodology with knowledge from implicit measures by using a decision RT paradigm. This should serve as a means to capture implicit aspects of attachment. This experiment evaluated participants' response to prototypic attachment sentences in association with their own attachment classification, measured with the Adult Attachment Projective Picture System (AAP). First the AAP was administered as the standardized interview procedure to 30 healthy participants, which were classified into a secure or insecure group. In the following experimental session, both experimenter and participants were blind with respect to classifications. One hundred twenty eight prototypically secure or insecure sentences related to the eight pictures of the AAP were presented to the participants. Their response and RTs were recorded. Based on the response (accept, reject) a continuous security scale was defined. Both the AAP classification and security scale were related to the RTs. Differentiated study hypotheses were confirmed for insecure sentences, which were accepted faster by participants from the insecure attachment group (or with lower security scale), and rejected faster by participants from secure attachment group (or with higher security scale). The elaborating unconscious processes were more activated by insecure sentences with potential attachment conflicts. The introduced paradigm is able to contribute to an experimental approach in attachment research. The RT analysis with the narrative procedure might be of interest for a broader variety of questions in experimental and neurophysiological settings to capture unconscious processes in association with internal working models of attachment. An electrophysiological model based on preliminary research is proposed for assessing the preconscious neuronal network related to secure or insecure attachment representations.
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http://dx.doi.org/10.3389/fnhum.2016.00548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5089988PMC
November 2016

High Prevalence of Insecure Attachment in Patients with Primary Hypertension.

Front Psychol 2016 3;7:1087. Epub 2016 Aug 3.

Institute of Psychology, University of Innsbruck Innsbruck, Austria.

Hypertension is a major cardiovascular (CV) risk factor and is predicted by heightened CV reactivity to stress in healthy individuals. Patients with hypertension also show an altered stress response, while insecure attachment is linked to a heightened stress reactivity as well. This is the first study aiming to assess attachment representations in patients with primary hypertension and to investigate their CV responses when their attachment system is activated. We studied 50 patients (38 men, 12 women) with primary hypertension. The Adult Attachment Projective Picture System (AAP), a widely used and validated interview, was performed to measure the patients' attachment representations, and to activate their attachment system. Blood pressure and heart rate were measured after 10 min at rest prior to and directly after the AAP interview. Mood and state anxiety were assessed using the Multidimensional Mood State Questionnaire (MDBF) and the State Trait Anxiety Inventory-State (STAI-S) before and after the experiment. The prevalence of insecure attachment (dismissing, preoccupied, unresolved) in hypertensive patients was predominant (88%), while in non-clinical populations, only about 50% of individuals had insecure attachment patterns. Blood pressure (p < 0.001), heart rate (p = 0.016), and rate pressure product (p < 0.001) significantly increased in response to the attachment interview. Secure attached patients showed the highest rise in systolic blood pressure (p = 0.020) and the lowest heart rate compared to the other attachment groups (p = 0.043). However, attachment representation showed no significant group or interaction effects on diastolic blood pressure (DBP) and rate pressure product. Insecure attachment was highly over-represented in our sample of patients with primary hypertension. Additionally, a robust CV response to the attachment-activating stimulus was observed. Our data suggest that insecure attachment is significantly linked to primary hypertension, which implies the need for further investigations to evaluate attachment insecurity as a possible risk factor for hypertension.
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http://dx.doi.org/10.3389/fpsyg.2016.01087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4971030PMC
August 2016

Neural Response during the Activation of the Attachment System in Patients with Borderline Personality Disorder: An fMRI Study.

Front Hum Neurosci 2016 2;10:389. Epub 2016 Aug 2.

Department of Psychiatry and Psychotherapy, Division of Mind and Brain Research, University Hospital Charité Berlin, Germany.

Individuals with borderline personality disorder (BPD) are characterized by emotional instability, impaired emotion regulation and unresolved attachment patterns associated with abusive childhood experiences. We investigated the neural response during the activation of the attachment system in BPD patients compared to healthy controls using functional magnetic resonance imaging (fMRI). Eleven female patients with BPD without posttraumatic stress disorder (PTSD) and 17 healthy female controls matched for age and education were telling stories in the scanner in response to the Adult Attachment Projective Picture System (AAP), an eight-picture set assessment of adult attachment. The picture set includes theoretically-derived attachment scenes, such as separation, death, threat and potential abuse. The picture presentation order is designed to gradually increase the activation of the attachment system. Each picture stimulus was presented for 2 min. Analyses examine group differences in attachment classifications and neural activation patterns over the course of the task. Unresolved attachment was associated with increasing amygdala activation over the course of the attachment task in patients as well as controls. Unresolved controls, but not patients, showed activation in the right dorsolateral prefrontal cortex (DLPFC) and the rostral cingulate zone (RCZ). We interpret this as a neural signature of BPD patients' inability to exert top-down control under conditions of attachment distress. These findings point to possible neural mechanisms for underlying affective dysregulation in BPD in the context of attachment trauma and fear.
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http://dx.doi.org/10.3389/fnhum.2016.00389DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4969290PMC
August 2016

Neural Correlates of the Appraisal of Attachment Scenes in Healthy Controls and Social Cognition-An fMRI Study.

Front Hum Neurosci 2016 5;10:345. Epub 2016 Jul 5.

Department of Clinical Psychology, Institute of Psychology, University of Innsbruck Innsbruck, Austria.

The human attachment system is activated in situations of danger such as potential separation, threats of loss of a significant other and potential insecurity on the availability of the attachment figure. To date, however, a precise characterization of the neural correlates of the attachment system in healthy individuals is lacking. This functional magnetic resonance imaging (fMRI) study aims at characterizing the distinctive neural substrates activated by the exposure to attachment vs. non-attachment scenes. Healthy participants (N = 25) were presented scenes from the Adult Attachment Projective Picture System (AAP), a validated set of standardized attachment-related pictures extended by a control picture stimulus set consisting of scenes without attachment-related content. When compared to the control neutral pictures, attachment scenes activated the inferior parietal lobes (IPLs), the middle temporal gyrus (MTG), and the anterior medial prefrontal cortex (mPFC). These areas are associated with reasoning about mental representations, semantic memory of social knowledge, and social cognition. This neural activation pattern confirms the distinctive quality of this stimulus set, and suggests its use as a potential neuroimaging probe to assess social cognition/mentalizing related to attachment in healthy and clinical populations.
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http://dx.doi.org/10.3389/fnhum.2016.00345DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932100PMC
July 2016

[Influence and Change of Self-Directedness in Dialectical Behavior Therapy].

Psychiatr Prax 2017 Jul 11;44(5):266-273. Epub 2016 Jul 11.

Klinik für Psychiatrie und Psychotherapie, Universität Greifswald.

Investigate influence and change of self-directedness (SD) in Dialectical-Behavior Therapy (DBT) for 26 female outpatients with borderline personality disorder (BPS). Variance analyses are used to evaluate psychopathology and interpersonal problems in 2 subgroups (low vs. high SD) with questionnaires at 3 measuring times over the period of 1 year. Low SD was associated with higher psychopathology, more interpersonal problems and lower symptomreduction. Over time of intervention the SD of all patients improved significantly. DBT strengthens the SD of patients with BPD. A screening of SD before intervention, and systematic support should be considered.
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http://dx.doi.org/10.1055/s-0042-104096DOI Listing
July 2017