Antonia Bifulco

Self-esteem and depression. II. Social correlates of self-esteem.

SummaryThe Self-Evaluation and Social Support Schedule (SESS), an interview-based instrument, is described, which aims to give a comprehensive description of a persons social milieu in terms of ‘objective’ and ‘subjective’ measures. On the basis of a population survey of 400 largely working-class women, a tentative causal model is developed which relates both the quality of current interpersonal ties and childhood experiences to current negative and positive measures of self-esteem. A major purpose of the execrise is to develop positive and negative indices of the social environment that can be used to elucidate the aetiological role of self-esteem in the development of depression. This is the task of a third paper.

Adult attachment style. I: Its relationship to clinical depression

Background Although there are an increasing number of studies showing an association of adult attachment style to depressive disorder, such studies have rarely utilised epidemiological approaches with large community-based series and have relied heavily on brief self-report measurement of both attachment style and symptoms. The result is a wide inconsistency in the type of insecure style shown to relate to disorder. The present study examined adult attachment style in a high-risk community sample of women in relation to clinical depression. It utilised an interview measure of adult attachment which allowed for an assessment of both type of attachment style and the degree of insecurity of attachment. A companion paper examines its relationship with other depressive-vulnerability (Bifulco et al. 2002). Method Two hundred and twenty-two high-risk and 80 comparison women were selected from questionnaire screenings of London GP patient lists and intensively interviewed. A global scale of attachment style based on supportive relationships (with partner and very close others) together with attitudes to support-seeking, derived the four styles paralleling those from self-report attachment assessments (Secure, Enmeshed, Fearful, Avoidant). In order to additionally reflect hostility in the scheme, the Avoidant category was subdivided into “Angry-dismissive” and “Withdrawn”. The degree to which attitudes and behaviour within such styles were dysfunctional (“non-standard”) was also assessed. Attachment style was examined in relation to clinical depression in a 12-month period. For a third of the series this was examined prospectively to new onset of disorder. Results The presence of any insecure style was significantly related to 12-month depression. However, when controls were made for depressive symptomatology at interview, only the “non-standard” levels of Enmeshed, Fearful or Angry-dismissive styles related to disorder. Withdrawn-avoidance was not significantly related to disorder. Conclusion The relationship of attachment style to clinical depression is increased by differentiating the degree of insecurity of style and differentiating hostile and non-hostile avoidance.

The childhood experience of care and abuse questionnaire (CECA.Q): validation in a community series.

BACKGROUND Childhood neglect and abuse, as measured by retrospective interview, is highly predictive of psychiatric disorder in adult life and has an important role in aetiological models. However, such measures are labour-intensive, costly, and thus restricted to relatively modest sample sizes. A compact self-report assessment of childhood experience is invaluable for research screening purposes and large-scale survey investigation. METHOD A self-report questionnaire (CECA.Q) was developed to mirror an existing validated interview measure: the childhood experience of care and abuse (CECA). The questionnaire assessed lack of parental care (neglect and antipathy), parental physical abuse, and sexual abuse from any adult before age 17. A high-risk series of 179 London women were interviewed using the CECA together with the PSE psychiatric assessment, and completed the CECA.Q at later follow-up. Repeat CECA.Qs were returned for 111 women and 99 women additionally completed the parental bonding instrument (PBI; Parker, Tupling, & Brown, 1979). RESULTS Satisfactory internal scale consistency was achieved on the CECA.Q for antipathy (alpha = .81) and neglect (alpha = .80) scales. There was satisfactory test-retest for both care and abuse scales. Significant associations were found between CECA.Q scales and the parallel interview scales with cut-offs determined for high sensitivity and specificity. CECA.Q neglect and antipathy scales were also significantly related to PBI parental care. CECA.Q scales were significantly related to lifetime history of depression. Optimal cut-off scores revealed significant odds ratios (average of 2) for individual scales and depression. When indices were compiled to reflect peak severity of each type of adversity across perpetrator, odds-ratios increased (average 3). A dose-response effect was evident with the number of types of neglect/abuse and rate of lifetime depression. CONCLUSION The CECA.Q shows satisfactory reliability and validity as a self-report measure for adverse childhood experience. The merits of having parallel questionnaire and interview instruments for both research and clinical work are discussed.

Predicting depression in women: the role of past and present vulnerability

BACKGROUND A prospective study, covering just over a 1-year period, sought to confirm an earlier finding that around 40% of women who experience a severe life event in the presence of two ongoing psychosocial vulnerability factors, (negative close relationships and low self-esteem) will develop a major depressive episode. Distal risk factors were examined to see if they improved prediction. METHODS A population sample of 105 mainly working-class mothers with vulnerability and without depression were interviewed three times over a 14-month period to date the occurrence of severe life events and onset of major depression. Degree of vulnerability was assessed at first contact together with distal risk in terms of childhood neglect/abuse and any earlier episodes of depression. RESULTS Thirty-seven per cent of these vulnerable women became depressed in the study period. The majority experienced a severe life event, and of these, 48% had onsets. Contrary to expectation, risk was only a little less among those with just one of the two vulnerability factors. Two-thirds of women with an onset had been depressed in previous years. Although this was associated with increased risk, the effect was greatest for those who had experienced an episode before age 20. A relationship between childhood neglect/abuse and onset was entirely accounted for by such early depression. CONCLUSION An aetiological model of depression outlined in earlier research was confined with a new factor of teenage depression shown to increase risk of onset.

Self-esteem and depression. III, Aetiological issues

SummaryThis is the last of a series of three papers dealing with the role of self-esteem in the onset of clinical depression. On the basis of a longitudinal population enquiry a comprehensive psychosocial model of depression is developend. It is concluded that self-esteem (primarily in terms of a negative measure) does play a significant role. However, this can be only properly interpreted in the light of the full model. This highlights: 1. the importance of the occurrence of both a negative enviromental factor (negative interaction with children or husband for married or negative interaction with children or lack of a very close tie for single mothers)and a negative psychological factor (low self-esteem or chronic subclinical condition); and 2. how a relatively small group of high risk women in these terms (23% of total at risk based on measures collected well of onset of depression occurring over a 12 month period.

Adult attachment style. II: Its relationship to psychosocial depressive-vulnerability.

Background A range of studies show adult attachment style is associated with depressive-vulnerability factors such as low self-esteem, poor support and childhood adversity. However, there is wide inconsistency shown in the type of insecure style most highly associated. Few studies have examined attachment style in relation to clinical depression together with a range of such factors in epidemiological series. The present study uses an interview measure of adult attachment which differentiates type of attachment style and degree of insecurity of attachment, to see: (a) if it adds to other vulnerability in predicting depression and (b) if there is specificity of style to type of vulnerability. Method Two hundred and twenty-two high-risk and 80 comparison women were selected from questionnaire screenings of London GP patient lists and intensively interviewed. The Attachment Style Interview (ASI) differentiated five styles (Enmeshed, Fearful, Angry-dismissive, Withdrawn and Standard) as well as the degree to which attitudes and behaviour within such styles were dysfunctional (‘non-standard’). Attachment style was examined in relation to low self-esteem, support and childhood experience of neglect or abuse, and all of these examined in relation to clinical depression in a 12-month period. Results The presence of any ‘non-standard’ style was significantly related to poor support, low self-esteem and childhood adversity. Some specificity of type of style and type of vulnerability was observed. Logistic regression showed that non-standard Enmeshed, Fearful and Angry-dismissive styles, poor support and childhood neglect/abuse provided the best model for clinical depression. Conclusion Non-standard attachment in the form of markedly Enmeshed, Fearful or Angry-dismissive styles was shown to be associated with other depressive-vulnerability factors involving close relationships, self-esteem and childhood adversity and added to these in modelling depression.

Self-esteem and depression. IV, Effect on course and recovery

SummaryThe present paper, the fourth and last in a series examining the role of self-esteem in depressive disorder in the general population, deals with recovery/improvement from a disorder at a case level. Both positive evaluation of self (NES) measured during a chronic episode are related to subsequent recovery or improvement. A causal effect is suggested since the measure adds over and above to that of environmental factors previously established to relate to recovery/improvement — the reduction of an ongoing difficulty or fresh-start event. Positive evaluation of self was also related to recovery/improvement from subsequentonsets of case depression. In this instance unlike that for the chronic conditions, self-esteem was measured outside the episode of depression. A causal effect was also suggested because it made an independent contribution vis-a-vis the effect of fresh-start events. Given the small size of the sample the study should be seen as an exploratory one.

Childhood Experience of Care and Abuse Questionnaire (CECA.Q). Validation of a screening instrument for childhood adversity in clinical populations.

Abstract.Background: Interview measures for investigating adverse childhood experiences, such as the Childhood Experience of Care and Abuse (CECA) instrument, are comprehensive and can be lengthy and time-consuming. A questionnaire version of the CECA (CECA.Q) has been developed which could allow for screening of individuals in research settings. This would enable researchers to identify individuals with adverse early experiences who might benefit from an in-depth interview. This paper aims to validate the CECA.Q against the CECA interview in a clinical population. Methods: One hundred and eight patients attending an affective disorders service were assessed using both the CECA interview and questionnaire measures. A follow-up sample was recruited 3 years later and sent the questionnaire. The questionnaire was also compared with the established Parental Bonding Instrument (PBI). Results: Agreement between ratings on the interview and questionnaire were high. Scales measuring antipathy and neglect also correlated highly with the PBI. The follow-up sample revealed the questionnaire to have a high degree of reliability over a long period of time. Conclusions: The CECA.Q appears to be a reliable and valid measure which can be used in research on clinical populations to screen for individuals who have experienced severe adversity in childhood.

Loss of parent in childhood and adult psychiatric disorder: A tentative overall model

Two previous reports on a female population sample in Outer London, UK, had identified certain environmental experiences–such as lack of adequate replacement care after parental loss in childhood, premarital pregnancy, and low social class and poor emotional support in adulthood–as key factors intervening between childhood loss of parent and depression in adulthood. A third paper introduced a measure of the cognitive set of situational helplessness-mastery which was associated, on the one hand, with current depression and, on the other, with loss of mother in childhood. This article examines the relationship between these other factors and situational helplessness both in childhood and in adulthood. Most are highly associated with the cognitive set, but the relationship between childhood helplessness and loss of mother appears to be differentially mediated according to whether the loss was by death or separation. A series of multivariate statistical analyses aims to integrate all the findings so far reported on in this sample into a biographical model of the developmental pathways from childhood loss of mother to current depression.

Adverse childhood experiences and their impact on frequency, severity, and the individual function of nonsuicidal self-injury in youth

This study aimed to investigate a specific relationship between nonsuicidal self-injury (NSSI) and a variety of adverse childhood experiences (ACEs) over and above childhood abuse and their impact on frequency, severity, and functions of NSSI. A sample of 125 inpatients (aged 13 to 26) was consecutively recruited within a psychiatric university hospital. Frequency, methods and functions of NSSI were assessed by the Functional Assessment of Self-Mutilation (FASM), ACEs were assessed by the Childhood Experiences of Care and Abuse Questionnaire (CECA.Q). The 12 month prevalence of NSSI in this representative, clinical sample was 60.0%. Engagement in NSSI was significantly related to ACEs with highest associations for maternal antipathy and neglect. Whilst ACEs were not associated with frequency or severity of NSSI, some ACEs were significantly related to the automatic functions of NSSI (e.g., affect regulation, anti-dissociative function or self-punishment) as well as to a peer identification function. NSSI represents a frequent phenomenon among young clinical populations and seems to be specifically related to ACEs with maternal antipathy or neglect commonly featured over and above experiences of abuse. Since ACEs also influence the functions of NSSI such factors need to be examined as part of clinical care planning.