Sarah I. F. Daniel

A Randomized Controlled Trial of Psychoanalytic Psychotherapy or Cognitive-Behavioral Therapy for Bulimia Nervosa

OBJECTIVE The authors compared psychoanalytic psychotherapy and cognitive-behavioral therapy (CBT) in the treatment of bulimia nervosa. METHOD A randomized controlled trial was conducted in which 70 patients with bulimia nervosa received either 2 years of weekly psychoanalytic psychotherapy or 20 sessions of CBT over 5 months. The main outcome measure was the Eating Disorder Examination interview, which was administered blind to treatment condition at baseline, after 5 months, and after 2 years. The primary outcome analyses were conducted using logistic regression analysis. RESULTS Both treatments resulted in improvement, but a marked difference was observed between CBT and psychoanalytic psychotherapy. After 5 months, 42% of patients in CBT (N=36) and 6% of patients in psychoanalytic psychotherapy (N=34) had stopped binge eating and purging (odds ratio=13.40, 95% confidence interval [CI]=2.45-73.42; p<0.01). At 2 years, 44% in the CBT group and 15% in the psychoanalytic psychotherapy group had stopped binge eating and purging (odds ratio=4.34, 95% CI=1.33-14.21; p=0.02). By the end of both treatments, substantial improvements in eating disorder features and general psychopathology were observed, but in general these changes took place more rapidly in CBT. CONCLUSIONS Despite the marked disparity in the number of treatment sessions and the duration of treatment, CBT was more effective in relieving binging and purging than psychoanalytic psychotherapy and was generally faster in alleviating eating disorder features and general psychopathology. The findings indicate the need to develop and test a more structured and symptom-focused version of psychoanalytic psychotherapy for bulimia nervosa.

AAI predicts patients’ in-session interpersonal behavior and discourse: a “move to the level of the relation” for attachment-informed psychotherapy research

There is currently little empirical evidence regarding how patients’ attachment patterns manifest in individual psychotherapy. This study compared the in-session discourse of patients classified secure, dismissing, and preoccupied on the Adult Attachment Interview (AAI). Rather than focusing on content or form alone, this study analyzed how patients’ discourse elicits and maintains emotional proximity with the therapist. The AAI was administered to 56 patients prior to treatment and one session for each patient was rated with the Patient Attachment Coding System (PACS) by four independent raters, blind to patients’ AAI classification. Significant differences were found in the discourse of patients with different attachment patterns. Namely, secure and preoccupied patients showed more contact-seeking behavior than dismissing patients, who avoided emotional proximity more, while preoccupied patients resisted therapists’ help more than did secure and dismissing patients. These results suggest that the different attachment patterns may have distinctive manifestations in the psychotherapy process that can be tracked by external observers.

The transmission of trauma in refugee families: associations between intra-family trauma communication style, children’s attachment security and psychosocial adjustment

ABSTRACT This study explores the transmission of trauma in 30 Middle Eastern refugee families in Denmark, where one or both parents were referred for treatment of PTSD symptoms and had non-traumatized children aged 4–9 years. The aim of the study was to explore potential risk and protective factors by examining the association between intra-family communication style regarding the parents’ traumatic experiences from the past, children’s psychosocial adjustment and attachment security. A negative impact of parental trauma on children might be indicated, as children’s Total Difficulties Scores on the Strengths and Difficulties Questionnaire (SDQ) were significantly higher than the Danish norms. A negative association between children’s attachment security as measured by the Attachment and Traumatization Story Task and higher scores on the SDQ Total Difficulties Scale approached significance, suggesting that the transmission of trauma may be associated with disruptions in children’s attachment representations. Furthermore a significant association between parental trauma communication and children’s attachment style was found.

Anxiety levels in clinically referred children and their parents: Examining the unique influence of self‐reported attachment styles and interview‐based reflective functioning in mothers and fathers

OBJECTIVE Although much is known about childhood anxiety disorders, the differential contributions by mothers and fathers to child anxiety is poorly understood. This study examined the relation between child anxiety and parental level of psychopathology, attachment style, and reflective functioning (RF). DESIGN Thirty-eight clinically anxious children aged 7-12 years (55.3% female) referred for treatment and their parents (37 mothers, 34 fathers) participated in the study. METHOD Reflective functioning was coded based on Adult Attachment Interviews. Self-report questionnaires on attachment and psychopathology were administered. RESULTS Paternal psychopathology, attachment avoidance, and attachment anxiety as well as maternal attachment anxiety were associated with child anxiety. Mothers had higher RF abilities than fathers. Lower levels of RF in mothers and higher levels of attachment avoidance in fathers explained 42% of the variance in anxiety levels of the child. CONCLUSION Mothers and fathers may provide unique contributions to the development of child anxiety. The findings highlight the importance of considering fathers as well as mothers in research and treatment for childhood anxiety disorders.

Subtypes in bulimia nervosa: the role of eating disorder symptomatology, negative affect, and interpersonal functioning

BACKGROUND The aim of the study was to investigate whether patients with bulimia nervosa (BN) could be subdivided into clinically meaningful groups reflecting the complex patterns of eating disorder symptoms and personality characteristics that face the clinician. METHODS Seventy patients diagnosed with BN using the Eating Disorder Examination were assessed with measures of negative affect, attachment patterns, and interpersonal problems. An exploratory hierarchical cluster analysis was performed. RESULTS The study found two main subtypes differing primarily in terms of symptom severity and level of negative affect, but these subtypes were further subdivided into four clinically relevant subtypes: A dietary restraint/negative affect/high symptomatic group, an emotionally overcontrolled group, a low dietary restraint/emotionally underregulated group, and a high functioning/securely attached group. CONCLUSIONS The study indicates that cluster-analytic studies, including a broad range of instruments measuring eating disorder symptoms as well as negative affect, relational patterns, and other personality characteristics, may contribute to an integration of previously suggested models of subtypes in BN.

The developmental roots of narrative expression in therapy: Contributions from attachment theory and research.

A central element in many forms of psychotherapy is the narrative articulation of client experience. From both theory, training, and practice, clinicians learn that structural aspects of client narratives may reveal important information about the client, but there is still limited research-based knowledge on this topic. This article explores and discusses the relevance of attachment theory and research to understanding structural and stylistic aspects of client narration in adult psychotherapy. Research into patterns of narrative expression identified by the Adult Attachment Interview (AAI) suggests that the emotional tone and structural organization of narratives are related to patterns of information processing and affect regulation originating in experiences in attachment relationships. Attachment research thus holds the potential of linking client in-session narration to findings in developmental psychology. Clinical implications of the AAI-related research are discussed in terms of the therapeutic significance of narrative coherence and the possible meaning of different kinds of narrative incoherence. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Adult attachment insecurity and narrative processes in psychotherapy: an exploratory study

Different types of client attachment insecurity may affect the psychotherapeutic process in distinct ways. This exploratory study compared the in-session discourse of clients with dismissing and preoccupied attachment states of mind on Adult Attachment Interviews conducted prior to therapy in the context of a randomized clinical trial of psychoanalytic and cognitive-behavioural psychotherapy for bulimia nervosa. In a subsample of six sessions from each of eight therapy dyads, preoccupied clients were found to talk more and have longer speaking turns than dismissing clients, who in turn generated more pauses. Using the Narrative Processes Coding System, preoccupied clients were found to show more narrative initiative; whereas, differences in terms of narrative process modes were not as clearly interpretable. Contrary to expectations, the two insecure states of mind were equally different in the relationship-focused psychoanalytic therapy and in the symptom-focused cognitive-behavioural therapy. Suggestions for further investigations of the in-session discourse of clients with different attachment states of mind are given. 

Client attachment in a randomized clinical trial of psychoanalytic and cognitive-behavioral psychotherapy for bulimia nervosa: Outcome moderation and change.

In the context of a randomized clinical trial of psychoanalytic psychotherapy (PPT) versus cognitive behavior therapy (CBT) for bulimia nervosa (BN), this study performed secondary analyses of (a) the relation between attachment and pretreatment symptom levels, (b) whether client pretreatment attachment moderated treatment outcome, (c) whether change in client attachment was associated with symptomatic change, and (d) whether client attachment changed differently in the 2 treatments. Sixty-nine women and 1 man of a mean age of 25.8 years diagnosed with BN were randomly assigned to either 2 years of weekly PPT or 5 months of CBT. Assessments at intake, after 5 months, and after 2 years included the Eating Disorder Examination to assess eating disorder symptoms, the Adult Attachment Interview to assess client attachment, and the Symptom Checklist 90-R to assess general psychiatric distress. Repeated measures were analyzed using multilevel analysis. Higher scores on attachment insecurity and attachment preoccupation were associated with more frequent binging pretreatment. Pretreatment attachment did not predict treatment outcome. In PPT, but not in CBT, reduction of binging was associated with an increase in attachment security. The 2 treatment types were not associated with significantly different patterns of attachment-related change. Degree and type of attachment insecurity is related to the frequency of binging in BN. Increase in attachment security may be a treatment-specific mechanism of change in PPT for BN. (PsycINFO Database Record

Client attachment and therapist feelings in the treatment of bulimia nervosa.

The relationship between client attachment and therapist postsession feelings was investigated in a randomized clinical trial of psychoanalytic psychotherapy (PPT) and cognitive behavior therapy (CBT) for bulimia nervosa. Therapists completed feeling word checklists after each session, and client attachment was assessed with the Adult Attachment Interview. A factor analysis identified 3 feeling factors, Happy/Enthusiastic, Overwhelmed/Moved, and Indifferent/Bored. Positive feelings were predominant, but PPT therapists reported more negative and fewer positive feelings than CBT therapists did. Client improvement in terms of frequency of bulimic episodes and general psychiatric distress was related to an increase in Happy/Enthusiastic feelings. Multilevel analyses indicated significant interactions between therapy type and client dismissing versus preoccupied attachment in predicting therapist negative emotional reactions. PPT therapist felt more Indifferent/Bored the more dismissing clients were, whereas CBT therapists felt more Overwhelmed/Moved the more preoccupied clients were.

Adult attachment style and anxiety – The mediating role of emotion regulation

BACKGROUND Although there is substantial evidence for the role of emotion regulation in the etiology and maintenance of anxiety disorders, knowledge about what contributes to emotion dysregulation is sparse. Attachment style is related to emotion regulation and anxiety symptoms, but these variables have rarely been examined together. Examining emotion dysregulation within the context of anxiety disorders through an attachment theory framework will lead to a better understanding of the etiology and maintenance of anxiety disorders. In the present study we combined theoretically and empirically derived knowledge to examine the mediating role of emotion regulation between attachment dimensions (avoidance and anxiety) and anxiety symptoms. METHODS A total of 147 individuals were assessed with Beck Anxiety Inventory (BAI), Experiences in Close Relationships-Revised (ECR-R) and Difficulties in Emotion Regulation Scale (DERS), and statistical mediation analyses were conducted. RESULTS Our results indicate that the significant association between anxiety and attachment anxiety was mediated by emotion dysregulation, whereas attachment avoidance was not significantly related to anxiety when covarying for attachment anxiety. The primary limitation of our study is that data is cross-sectional and so causation cannot be inferred. Secondly, all measures used in this study were derived from self-reported questionnaires, which may be more susceptible to bias. CONCLUSIONS Our results suggest that it is not insecure attachment in general that is important in anxiety disorders, but that attachment anxiety is specifically relevant. Thus, clinical interventions for anxiety disorders may improve by targeting attachment related difficulties.