Antonia Bifulco

1
Attachment style and depression in adults Using
a lifespan model

• Antonia Bifulco
• Professor of Lifespan Psychology Social Science
• Kingston University

2
An Attachment approach(Bowlby, 1969-80
Attachment and Loss trilogy)

• Attachment theory is a lifespan approach -
  childhood experience to adult relationships and
  disorder.
• Attachment style is determined by internal
  working models - guidance system for
  relationships based on memories of past
  interactions and expectations of future ones.
• Distortion occurs through parental rejection (eg
  physical abuse), helplessness (eg neglect) or
  absence (eg separation).
• Internal working models determine the type of
  attachment style in adulthood those Anxious or
  Avoidant or Disorganised versus Secure.
• As yet there is no consensus about which
  childhood experiences relate to which style,
  although all relate to Insecure style in general.

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Attachment style assessment is a powerful tool
for psychologists

• Attachment style is shown to relate to emotional
  behavioural disorder (Dozier et al 1999) as
  part of a bio-psychosocial developmental model
  (Perry et al 1995).
• However, its wider use, particularly in clinical
  practice, has been hampered by measures which
  are too superficial (eg RQ, Bartholomew
  Horowitz, 1991) or too intensive (AAI,George,
  Kaplan, Main 1994) and by inconsistency of style
  definition.
• We introduce the Attachment Style Interview as a
  user-friendly measure to progress research and
  practice.

4
Psychosocial model of attachment style and
disorder
Social factors
Mediating effect
Major Depression or anxiety onset
Neglect or Abuse lt17
Insecure Attachment Style in adults
Psychological factors
Biological factors
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Intensive study of London women

• Study aims
• Insecure attachment style will relate to
  emotional disorder in women
• Childhood neglect/abuse will relate to insecure
  attachment style.
• Insecure style will act as a mediator
• There will be some specific associations for
  different attachment styles.
• Procedure
• 303 London women selected by screening
  questionnaire from GP lists for high psychosocial
  risk for depression. Contacted for lengthy
  face-to-face interview on
• childhood experience (CECA)
• attachment style (ASI)
• Major Depression and Anxiety disorder. (SCID)
• 154 followed-up 3 years later for onset of
  depression or anxiety.

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Measures - Attachment Style Interview (ASI)

• A measure of attachment style in relation to
  on-going poor supportive contexts.
• Three close supportive relationships (partner and
  Very Close other) questioned about in detail. If
  one or fewer supportive relationships then poor
  ability to relate and insecure style rated.
• Attitudes towards closeness, trust and autonomy
  questioned around
• Anxious attitudes (fear of rejection, fear of
  separation, desire for company)
• Avoidant attitudes (mistrust, constraints on
  closeness, high self-reliance, anger)
• Overall attachment styles derived 4 insecure
  and Secure.
• All insecure styles rated as marked, moderate
  or mild level of insecurity or dysfunction.
• Good inter-rater reliability (Kappa0.80
  correlation London study Kappa0.70 EU study)

Bifulco, Moran, Ball Bernazzani (2002)Adult
Attachment Style Its Relationship to clinical
depression, SPPE 37 50-59
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Attachment style classification (ASI)

• Dual/disorganised
• Combined insecure style ratings, usually Anxious
  Avoidant
• Anxious styles
• Enmeshed (low self-reliance, fear of separation,
  high need for company).
• Fearful (mistrust, constraints on closeness fear
  rejection)
• Avoidant styles
• Angry-dismissive (mistrust self-reliance, anger)
• Withdrawn (constraints on closeness
  self-reliance)
• Secure

Cartoons are used in a child version being piloted
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Attachment styles relate to survival strategies
of fight, flight, cling and hide
Fearful styles run
Enmeshed styles cling
Withdrawn styles hide
Angry-dismissive styles fight
Secure styles seek help
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Measures - Clinical, SCID for DSM-IV

• Interview to determine both number and severity
  of symptoms over the prior 12 months and at
  follow-up.
• Depression
• Depressed mood/loss of interest and four or more
  key symptoms categorised as cases, together with
  significant distress/impairment.
• Minimum length of episode 4 weeks. The average
  length proved to be 4 months. Half lasted 12
  months or more.

• Anxiety disorders
• Generalised Anxiety Disorder
• Social Phobia
• Panic/Agoraphobia
• Rates of Disorder
• 35 MDD in year before interview 1
• 36 MDD and 40 anxiety at follow-up interview 2
  
• 20 GAD, 10 social phobia, 12 panic/agoraphobia

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Childhood Experience of Care and Abuse
(CECA)

• Interview to determine type and severity of
  childhood neglect and abuse experiences before
  age 17.
• Factual focus to aid reliability. Probes for
  timing, sequence and details of experiences.
• Lack of care (neglect, antipathy role reversal)
• Abuse (physical, psychological sexual).
• All experiences rated marked, moderate, mild or
  none. Marked/ moderate termed severe.
• Index of severe neglect, physical abuse sexual
  abuse derived, 55 of women scored on index.
• Good inter-rater reliability (above .70). Good
  validity determined by sibling accounts

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Finding 1 Attachment style
Depression(N303, interview 1)
major depression in 12 months
Insecure attachment Odds-ratio Wald df Plt
Highly Enmeshed 5.83 10.65 1 0.001
Highly Fearful 3.64 8.72 1 0.003
Highly Angry-dismissive 5.01 11.80 1 0.0006
Highly Withdrawn 2.02 1.54 1 NS
Mildly insecure style 1.22 0.30 1 NS
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Childhood adversity, attachment style and
depression
Childhood adversity index was double in women
with insecure style 58 vs 29. plt.001
Withdrawn style excluded
Mediation shown
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Attachment style and depression
specificity(Loglinear analysis)
Highly Enmeshed
ns
.26
.23
Highly Fearful
.19
Neglect or Abuse lt17
Major Depression
.28
.19
Highly Angry- dismissive
ns
ns
Highly Withdrawn
Mediation confirmed for Fearful and
Angry-dismissive style
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Finding 2 Type of attachment style and anxiety
disorder in follow-up (N154)
Attachment style interview 1 Anxiety disorder GAD Social Phobia Panic/Agora
Enmeshed NS NS NS NS
Fearful 0.16 NS 0.21 NS
Angry-dismissive 0.17 0.18 NS NS
Withdrawn NS NS NS NS
plt .01, ,001, .0001
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Mediating role of attachment style-Case Anxiety
Interview 1--------------------Interview 2
Case Anxiety Follow-up
Highly insecure Attachment Style
Neglect or Abuse in childhood
.33
.33
Withdrawn style excluded
Mediation confirmed
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Specificity - childhood experience and attachment
style
CECA
ASI styles
Lack of Care
Antipathy
.15
Enmeshed
Neglect
.12
.20
Fearful
Role reversal
.19
.14
Angry-dismissive
Physical
.12
.14
.17
Psychological
Sexual
Withdrawn
Abuse
plt.05, plt.01
17
Childhood experiences and style regression
analyses
ASI
CECA
Anxious style (Enmeshed or Fearful)
Severe Lack of care (Antipathy or Neglect Or Role
Reversal
OR4.19
Severe Abuse (Physical, Sexual or Psychological)
Angry-Dismissive style
OR4.51
OR significant odds ratios taken from binary
logistic regression analyses. plt.05

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

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Implications

• Insecure attachment style mediates the
  relationship between early adverse experience and
  adult major depression and anxiety. Some
  specificity of style to experience and disorder
  is shown.
• Early intervention in childhood to protect
  against neglect/abuse or in early adulthood to
  ameliorate attachment style can reduce disorder
  in adult life.
• Improving the quality of adult relationships and
  support can reduce attachment insecurity.
• Clinical psychologists, CAMHS and perinatal
  psychologists can benefit from assessing
  attachment style in clients or their parents.
• The ASI as a research-based assessment tool is
  available for practice contexts to utilise this
  evidence-base in child and family social services
  and psychological services to aid best practice.

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Thank you for your attention

• antonia.bifulco_at_kingston.ac.uk