Florian Juen

Klinische Bindungsforschung mit dem Adult Attachment Projective Picture System: Methodik, klinische Anwendung und Perspektiven

ZusammenfassungDas Adult Attachment Projective Picture System (AAP) ist ein valides, reliables Instrument zur Erfassung der Bindungsrepräsentation bei Erwachsenen. Es sind bereits vielfältige klinische und neurobiologische Studien mit diesem Instrument durchgeführt worden, die in dieser Übersicht zusammengefasst werden. Wir berichten anhand von Fallbeispielen störungsspezifische Charakteristika anhand von AAP-Narrativen von Patienten. Zusammenfassend ist festzuhalten, dass im klinischen Kontext das AAP bei verschiedenen Störungsbildern auch im Rahmen von Psychotherapieforschung valide einsetzbar ist. Die ökonomische Durchführung des AAP eignet sich sehr gut dazu, das AAP auch in der klinischen Routine einzusetzen. Dieses Instrument kann auch für den Jugendbereich angewandt werden. Noch gibt es wenige Untersuchungen mit diesen Methoden zur Veränderbarkeit von Bindung durch Psychotherapie. Wir berichten über die Ergebnisse einer Psychoanalyse-Studie, bei der erstmals bei chronisch depressiven Patienten neben der symptomatischen Veränderung die signifikante Veränderung von unverarbeiteten Traumata nach 15 Monaten psychoanalytischer Behandlung sowie neuronale Veränderungen in depressionsrelevanten Arealen festgestellt wurden. Dazu wurde ein fMRT-Paradigma mit dem AAP eingesetzt. Die jeweils modifizierte Anwendung des AAP im neurowissenschaftlichen Kontext eröffnet neue Möglichkeiten für die experimentelle Untersuchung neuronaler Korrelate von Bindungsmustern bei Gesunden und Patienten. Befunde zu neuronalen Korrelaten von Bindungstraumata bei Borderline-Patientinnen untermauern einen klinisch relevanten Aspekt des Verlassenwerdens und Alleinseins bei dieser Patientengruppe.AbstractThe Adult Attachment Projective Picture System (AAP) is an established, reliable and valid representational measure of attachment for adults. In this review we report on several studies using the AAP in the clinical and neurobiological context. Moreover we demonstrate some disorder specific characteristics in patients with different disorders in their AAP narratives. In sum the AAP is valid for assessing attachment representations in several clinical disorders in the context of psychotherapy research. The economic administration allows to apply the AAP also in the clinical routine. This measure can also be administered in adolescent participants. There are only a small number of studies examining the change of attachment status during psychotherapy. We report on a study in depressed patients and their significant change from disorganized to organized attachment representations after 15 months of psychoanalytic treatment. This study identified neural changes in patients using an adapted AAP-fMRI paradigm to assess their improvement on a neural level. The feasibility of the AAP in an fMRI environment opens new possibilities to examine neural correlates of attachment. An fMRI study on Borderline patients with attachment trauma revealed clinically relevant results, concerning the patients’ intolerance of aloneness.

Siblings of children with cancer—the price they pay to function

When a child is diagnosed with cancer, this might generate an existential crisis and the emotional balance of the entire family is deeply disturbed. This is also because parental attention, worries and care strongly focus on the sick child. When there are siblings, there is no doubt that they are also in need of their parents’ care and attention to adjust to this challenging situation. Being exposed to cancer increases the risk of adverse mental reactions in combination with other risk factors such as low social support, pre-existing adjustment problems or parental mental disease. Empirical findings regarding quality, quantity and intensity of specific reactions of siblings to a cancer diagnosis are inconsistent. Whereas some researchers point to a higher prevalence of psychopathology, such as behavioural and mood disorders or impaired development among these children, others do not report any abnormalities at all [1–3]. These heterogenous findings are likely to be due to the diversity of accompanying risk factors, as well as to different times and intervals of assessment. Further reasons might be the diversity of (a) research methods (questionnaires vs. interviews), (b) dimensions observed (behavioural outcome vs. intrapsychic effort) or (c) the sources of information (self vs. proxy rating). Questionnaires provide adequate behavioural screening; however, when used as a single measure, they may not always be sufficiently sensitive in assessing subjective and affective dimensions. With questionnaires alone, we might underestimate aspects of the burden siblings suffer from and not be able to detect precursors of maladaptive development. For this reason, we advocate the use of complementary assessment methods in order to study siblings’ specific intrapsychic reactions and adjustment to this challenging experiences. In child and adolescent psychiatry and psychosomatic medicine, we use child’s play as a valuable source of information about the child’s inner world. The Mac Arthur Story Stem Battery (MSSB) is a standardized self-report measure designed to assess the intrapsychic strain and conflicts of children [4]. By acting out the beginnings of conflictual stories, the interviewer seeks to generate emotional tension within the child. Once the interviewer has told the beginning of the story, the child is asked to continue it and to show and tell what happens next. The narration and the way the child plays with the figurines provide insight into its inner world, its fears and wishes [5, 6]. The child’s stories also yield information about how it deals with present problems. As we know from other studies, the MSSB is sensitive to intrapsychic changes even weeks or months before behavioural outcomes are observed using questionnaires [7]. In the present study, we compared 14 siblings of children diagnosed with cancer (7 girls, 7 boys) with a matched control Andreas Guggemos and Florian Juen contributed equally to this work.

Aspekte der Mentalisierungsdiagnostik bei Kindern

Clinical relevance of variations within the ability to mentalize is usually reported in the field of psychopathology in adults. This might be due to difficulties in methods for empirical assessment of this capacity in children. In this short report the author discusses facets and abilities of how to engage the inner world of young children with story stem techniques and especially how to register variations in the ability to mentalize. Ideas for assessment in early childhood are presented and illustrated along two clinical vignettes. This paper gives a short impression of clinical diagnostics of mentalization in childhood.