The Mediational Effect of Affect Dysregulation on the Association Between Attachment to Parents and Oppositional Defiant Disorder Symptoms in Adolescents

Oppositional defiant disorder (ODD) is a childhood disorder, commonly occurring in early school aged children with some symptoms becoming normative in adolescence (e.g., irritability, disagreeing). Affect dysregulation is a risk factor in the development of ODD. Affect regulation is nurtured within parent–child relationships, thus disruptions to attachment may derail children’s capacity to develop adaptive affect regulation, increasing the risk for ODD. Using a high-risk sample of adolescents, we investigated the association between attachment anxiety and attachment avoidance with ODD through affect dysregulation. Attachment anxiety, but not avoidance, was associated with affect dysregulation and ODD. Affect dysregulation was found to fully mediate the relationship between attachment anxiety and ODD concurrently and prospectively. Similar findings have been demonstrated among children; results show that attachment anxiety, and its effects on affect dysregulation, are associated with ODD symptoms well into adolescence.

     

HPA system regulation and adult attachment anxiety: individual differences in reactive and awakening cortisol

Early life experiences can influence hypothalamus–pituitary–adrenal (HPA) axis regulation in adulthood, in both animals and humans. In humans, they have also been shown to influence adult attachment styles. However, the relationship between adult attachment styles and HPA axis regulation is largely unexplored. The present study investigated the relationship among varying levels of attachment anxiety and avoidance with both the cortisol response to acute stress (CRS) and the cortisol response to awakening (CRA) in 48 adult women. Attachment-unrelated stress was induced by a laboratory stress task. Saliva for free cortisol assessment was sampled before and after the stress task in the laboratory and at home on 2 consecutive days in the morning after awakening. We found that attachment anxiety but not attachment avoidance was associated with cortisol measures. Attachment anxiety was positively correlated with CRS and negatively with CRA. Finally, the two cortisol parameters were negatively associated with one another. The results are discussed with respect to (1) recent findings suggesting that the HPA system and hippocampus are programmed during critical development periods, establishing a certain trajectory of physiological responsiveness throughout life, and (2) a model that links development of the hippocampus with self development.     

Attachment style,affective loss and gray matter volume: A voxel‐based morphometry study

Early patterns of infant attachment have been shown to be an important influence on adult social behavior. Animal studies suggest that patterns of early attachment influence brain development, contributing to permanent alterations in neural structure; however, there are no previous studies investigating whether differences in attachment style are associated with differences in brain structure in humans. In this study, we used Magnetic Resonance Imaging (MRI) and voxel‐based morphometry (VBM) to examine for the first time the association between attachment style, affective loss (for example, death of a loved one) and gray matter volume in a healthy sample of adults (n = 32). Attachment style was assessed on two dimensions (anxious and avoidant) using the ECR‐Revised questionnaire. High attachment‐related anxiety was associated with decreased gray matter in the anterior temporal pole and increased gray matter in the left lateral orbital gyrus. A greater number of affective losses was associated with increased gray matter volume in the cerebellum; in this region, however, the impact of affective losses was significantly moderated by the level of attachment‐related avoidance. These findings indicate that differences in attachment style are associated with differences in the neural structure of regions implicated in emotion regulation. It is hypothesized that early attachment experience may contribute to structural brain differences associated with attachment style in adulthood; furthermore, these findings point to a neuronal mechanism through which attachment style may mediate individual differences in responses to affective loss. Hum Brain Mapp, 2010. © 2010 Wiley‐Liss, Inc.     

Do emotion regulation,attentional control,and attachment style predict response to cognitive behavioral therapy for anxiety disorders? – an investigation in clinical settings

Abstract

Objective: Approximately, 50% of all individuals with anxiety disorders do not benefit from the “gold standard” treatment, namely cognitive behavioral therapy (CBT). Reliable predictors of treatment effect are lacking. The primary aim of this study was to investigate the predictive value of emotion regulation, attentional control, and attachment style for group-based CBT outcomes in routine clinical settings. Method: A total of 76 patients with anxiety disorders received manual-based group CBT at psychiatric outpatient clinics. Emotion regulation, attachment style, and attentional control were assessed with self-report measures and with an experimental computer-based attentional control task at baseline. The severity of anxiety was assessed at intake, post-treatment, and at a 6-month follow-up. Results: Attentional control, emotion regulation, and attachment avoidance did not predict treatment outcomes. Higher attachment anxiety at baseline was significantly related to poorer outcome. Conclusion: In routine clinical settings, high attachment anxiety may predict poorer outcomes for group-based CBT.     

The impact of attachment insecurity and sleep disturbance on symptoms and sick days in hospital-based health-care workers

Objective

Adult attachment insecurity is associated with many health outcomes and may be associated with sleep disturbance. The purpose of this study was to test the hypothesis that sleep disturbance mediates the relationship between attachment insecurity and three measures of health (perceived general health, physical symptoms and sick days) in a group that is at high risk of sleep disturbance: hospital based health-care workers.

Methods

One hundred thirty-one nondepressed female hospital workers completed self-report measures of adult attachment, sleep disturbance, depressive symptoms (excluding sleep-related items) and health outcomes. The hypothesis of mediation was tested with sequential regression analyses.

Results

Both attachment anxiety and attachment avoidance were significantly associated with impairment in global sleep quality (ρ=.20 and .19, respectively, P<.05) and physical symptoms (ρ=.21 and .19, P<.05). Attachment anxiety was also associated with depressive symptoms (ρ=.33, P<.001) and sick days (ρ=.21, P<.05). For both physical symptoms and sick days, mediation analyses were consistent with global sleep quality acting as a partial mediator of the relationship between attachment anxiety and physical health. Non-sleep-related depressive symptoms were a stronger mediator.

Conclusions

This study corroborates evidence that attachment insecurity is associated with sleep disturbance and extends this association to the occurrence of physical symptoms and time off work due to sickness among workers in a high-stress occupation.     

Improvement in adult anxious and avoidant attachment during cognitive behavioral therapy for panic disorder

Objective: This study examined attachment within the framework of cognitive behavioral therapy (CBT) for panic disorder with agoraphobia (PDA) by measuring the changes in avoidant and anxious attachment in a session-by-session analysis. Method: Thirty-one patients with PDA were treated using CBT. Pre-session data on attachment style (ECR), avoidance behaviors (MI-alone: MI-al; MI-accompanied: MI-ac), anxiety sensitivity (ASI), emotion regulation (ERQ), and working alliance (WAI) were collected. Mixed model analyses were conducted to estimate relationship between changes in attachment, PDA symptoms, and related measures. Results: Variables improved during therapy. Changes in ASI were positively related to changes in avoidant and anxious attachment. Changes in MI-al, but not MI-ac, were related to changes in ECR. Changes in ASI and MI-al predicted changes in ECR-anxiety in the following session, but not vice versa. Similarly, changes in avoidance behaviors and ERQ-suppression, preceded changes in ECR-avoidance unidirectionally. Whereas WAI significantly improved, its variability was related only to simultaneous changes in ECR-anxiety. Conclusions: Overall, avoidant and anxious attachment improved during CBT for PDA. This change was related to and preceded by improved anxiety sensitivity, avoidance behaviors, and emotion regulation. These findings suggest that CBT for panic probably has downstream effects on attachment representations.

Clinical or methodological significance of this article: This is the first report of changes in attachment via cognitive behavioral therapy for panic disorder. Data were examined using repeated measures session by session, allowing for examination of temporal precedence of changes. Results revealed that anxiety sensitivity, avoidance, and suppression preceded changes in attachment. Results are discussed in the framework of modern attachment theory models.     

The association between affect amplification and urgency

Background: Individuals lacking effective coping skills to manage aversive affective states are more likely to behave impulsively despite harmful long‐term consequences. Urgency or the propensity to act rashly in response to negative affect is associated with a host of maladaptive behaviors. However, relatively little research has evaluated the impact of affective variables—such as emotion regulation—on urgency. Moreover, the role of urgency has not been examined in populations with mood and anxiety disorders, a group for whom maladaptive coping and avoidance behaviors are common responses to heightened affect. This study evaluated the association between urgency and three variables associated with the amplification of affect (anxiety sensitivity (AS), access to emotion regulation strategies, and distress intolerance). Methods: Data were collected from an unselected community sample ( n = 297) and a clinical sample with a mood and/or anxiety disorder ( n = 99). Results: Results from a linear regression indicated significant associations between both distress intolerance and emotion regulation strategies and urgency. AS was significantly associated with urgency when considered alone, but did not remain significant when considered in the context of an alternative measure of distress intolerance and emotion regulation. Conclusions: These findings suggest that intolerance of distressing states and lack access to a repertoire of emotion regulation strategies are strongly associated with acting impulsively in response to negative affect. Treatment implications and future research directions are discussed. Depression and Anxiety, 2011. © 2011 Wiley Periodicals, Inc.     

Reduced gray matter volume in ventral prefrontal cortex but not amygdala in bipolar disorder: Significant effects of gender and trait anxiety

Neuroimaging studies in bipolar disorder report gray matter volume (GMV) abnormalities in neural regions implicated in emotion regulation. This includes a reduction in ventral/orbital medial prefrontal cortex (OMPFC) GMV and, inconsistently, increases in amygdala GMV. We aimed to examine OMPFC and amygdala GMV in bipolar disorder type 1 patients (BPI) versus healthy control participants (HC), and the potential confounding effects of gender, clinical and illness history variables and psychotropic medication upon any group differences that were demonstrated in OMPFC and amygdala GMV. Images were acquired from 27 BPI (17 euthymic, 10 depressed) and 28 age- and gender-matched HC in a 3T Siemens scanner. Data were analyzed with SPM5 using voxel-based morphometry (VBM) to assess main effects of diagnostic group and gender upon whole brain (WB) GMV. Post-hoc analyses were subsequently performed using SPSS to examine the extent to which clinical and illness history variables and psychotropic medication contributed to GMV abnormalities in BPI in a priori and non-a priori regions has demonstrated by the above VBM analyses. BPI showed reduced GMV in bilateral posteromedial rectal gyrus (PMRG), but no abnormalities in amygdala GMV. BPI also showed reduced GMV in two non-a priori regions: left parahippocampal gyrus and left putamen. For left PMRG GMV, there was a significant group by gender by trait anxiety interaction. GMV was significantly reduced in male low-trait anxiety BPI versus male low-trait anxiety HC, and in high- versus low-trait anxiety male BPI. Our results show that in BPI there were significant effects of gender and trait-anxiety, with male BPI and those high in trait-anxiety showing reduced left PMRG GMV. PMRG is part of medial prefrontal network implicated in visceromotor and emotion regulation.     

Experiential avoidance and emotion regulation difficulties in hoarding disorder

Experiential avoidance can be defined as the tendency to avoid contact with unwanted internal experiences. Current conceptualizations of pathological hoarding appear broadly consistent with an experiential avoidant model. Eighty participants in four groups, namely hoarding disorder (HD) without comorbid obsessive–compulsive disorder (OCD), HD with comorbid OCD, non-hoarding OCD, and healthy controls, were administered measures of experiential avoidance and emotion regulation difficulties. Hoarding individuals reported higher levels of experiential avoidance and difficulties in emotion regulation compared to healthy but not to OCD participants. Both experiential avoidance and emotion regulation difficulties were significantly more prominent when HD was comorbid with OCD than when HD occurred without comorbid OCD. Correlation analyses further showed that both experiential avoidance and emotion regulation were moderately but significantly associated with obsessive–compulsive but not hoarding symptoms. Thus, experiential avoidance and emotion regulation difficulties are not specifically relevant to HD but to a broad range of psychopathologies. However, despite the lack of specificity, the findings raise some potentially useful clinical implications for the treatment of HD.     

Attachment in OCD: A meta-analysis

IntroductionIt has been proposed to extend the cognitive-behavioural model of obsessive-compulsive disorder (OCD) with attachment theory to shed light on the affective and developmental factors underlying the disease. With a growing number of empirical studies on the subject, this meta-analysis aims to quantify a possible relationship between attachment insecurity and OCD.MethodsA systematic search was conducted for studies in adult populations of patients with OCD as well as general populations displaying symptoms of OCD. Effect sizes of attachment anxiety and attachment avoidance were calculated separately. Covariates of demographic variables were used in meta-regressions.ResultsSixteen studies were included. Meta-analyses showed an association of medium to large effect size (Hedges’ g = 0.69; 95 % CI 0.58 – 0.80; p < 0.001) between OCD and attachment anxiety, and an association of medium effect size (Hedges’ g = 0.47; 95 % CI 0.39 – 0.54; p < 0.001) between OCD and attachment avoidance. Effect sizes in OCD population and general population studies did not differ significantly.DiscussionRobust effect sizes of both attachment anxiety and avoidance in relation to OCD symptomatology corroborate an attachment-centred view of OCD. These findings furthermore suggest that integrating cognitive and attachment-based therapeutic approaches to OCD may benefit patients in which developmental or emotional factors hinder successful treatment.     

Structural and functional neural correlates of self-reported attachment in healthy adults: evidence for an amygdalar involvement

The concept of attachment in long-term interpersonal relationships has been linked to relationship outcome and social-emotional health. To date, no relationship between the structural properties of the human amygdala and attachment in romantic relationships (measured through self-reported attachment related anxiety and avoidance) has been described. The aim of the current study was to investigate the relationship between amygdala structure as well as amygdala structural and functional connectivity and attachment anxiety and avoidance. To this end, we collected self-report attachment data on a sample of female young adults. We then examined associations between attachment and mean diffusivity, fractional anisotropy and resting state functional connectivity MRI (rs-FC) of the amygdala and its white matter connections with the prefrontal cortex. We found that lower integrity of the left amygdala was linked with attachment avoidance (e.g., being less comfortable in seeking proximity with others and depending on others) and that greater structural integrity of the uncinate fasciculus was positively associated with avoidance. Lastly, we found that stronger rs-FC between the bilateral amygdala and medial prefrontal regions was linked with greater avoidance. Our findings are compatible with and expand previous results reported by studies that have taken a task-related fMRI approach, furthering our understanding of the neurobiological mechanisms of attachment, and in particular implicating the system formed by amygdala and prefrontal areas in the patterns of behavior that regulate emotional proximity in romantic relationships. These findings have the potential to further our understanding of the affective mechanisms underlying attachment behavior.     

Do neural responses to rejection depend on attachment style? An fMRI study

Social bonds fulfill the basic human need to belong. Being rejected thwarts this basic need, putting bonds with others at risk. Attachment theory suggests that people satisfy their need to belong through different means. Whereas anxious attachment is associated with craving acceptance and showing vigilance to cues that signal possible rejection, avoidant attachment is associated with discomfort with closeness and using avoidant strategies to regulate one's relationships. Given these different styles by which people satisfy their need to belong (that can operate simultaneously within the same individual), responses to social rejection may differ according to these individual differences in attachment anxiety and avoidance. To test this hypothesis, we used neuroimaging techniques to examine how the degree to which people display each of the two attachment dimensions (anxiety and avoidance) uniquely correlated with their neural activity during a simulated experience of social exclusion. Anxious attachment related to heightened activity in the dorsal anterior cingulate cortex (dACC) and anterior insula, regions previously associated with rejection-related distress. In contrast, avoidant attachment related to less activity in these regions. Findings are discussed in terms of the strategies that individuals with varying attachment styles might use to promote maintenance of social bonds.     

Adult separation anxiety and unsettled infant behavior: Associations with adverse parenting during childhood and insecure adult attachment

ObjectiveThis study examined the prevalence and correlates of Adult Separation Anxiety Disorder (ASAD) and Adult Separation Anxiety (ASA) symptoms in a sample of first-time mothers with an unsettled infant during the first postpartum year.MethodsEighty-three primiparous women admitted to a residential parent–infant program participated in a structured clinical interview for DSM-IV diagnosis and questionnaires assessing ASA symptoms, adult attachment and childhood parenting experiences. Nurses recorded infant behavior using 24-hour charts.ResultsThe prevalence of ASAD in this sample was 19.3% and women with ASAD were, on average, more likely to be diagnosed with depression and anxiety disorders, report aversive parenting experiences during childhood and show adult attachment style insecurity. Both ASAD and ASA symptoms were predicted by adult attachment anxiety, and ASAD was associated with unsettled infant behavior. Attachment anxiety and attachment avoidance mediated relations between parental over-control and ASAD diagnosis, and between parental abuse and ASAD diagnosis. Attachment anxiety mediated the relation between parental over-control and ASA symptoms, and attachment avoidance mediated the relations of parental over-control and parental abuse with ASA symptoms.ConclusionsThis study highlights the prevalence of ASAD among first time mothers experiencing early parenting difficulties and the roles of childhood parenting experiences and adult attachment style in the development of the disorder. This points to the importance of introducing universal screening for ASAD in postnatal settings, and for the development of targeted interventions.     

Effective emotion regulation strategies improve fMRI and ECG markers of psychopathology in panic disorder: implications for psychological treatment action

Impairments in emotion regulation are thought to have a key role in the pathogenesis of anxiety disorders, but the neurobiological underpinnings contributing to vulnerability remain poorly understood. It has been a long-held view that exaggerated fear is linked to hyperresponsivity of limbic brain areas and impaired recruitment of prefrontal control. However, increasing evidence suggests that prefrontal–cortical networks are hyperactive during threat processing in anxiety disorders. This study directly explored limbic–prefrontal neural response, connectivity and heart-rate variability (HRV) in patients with a severe anxiety disorder during incidental versus intentional emotion regulation. During 3 Tesla functional magnetic resonance imaging, 18 participants with panic disorder and 18 healthy controls performed an emotion regulation task. They either viewed negative images naturally (Maintain), or they were instructed to intentionally downregulate negative affect using previously taught strategies of cognitive reappraisal (Reappraisal). Electrocardiograms were recorded throughout to provide a functional measure of regulation and emotional processing. Compared with controls, patients showed increased neural activation in limbic–prefrontal areas and reduced HRV during incidental emotion regulation (Maintain). During intentional regulation (Reappraisal), group differences were significantly attenuated. These findings emphasize patients'' ability to regulate negative affect if provided with adaptive strategies. They also bring prefrontal hyperactivation forward as a potential mechanism of psychopathology in anxiety disorders. Although these results challenge models proposing impaired allocation of prefrontal resources as a key characteristic of anxiety disorders, they are in line with more recent neurobiological frameworks suggesting that prefrontal hyperactivation might reflect increased utilisation of maladaptive regulation strategies quintessential for anxiety disorders.     

Examining the associations between emotion regulation difficulties,anxiety, and eating disorder severity among inpatients with anorexia nervosa

ObjectiveThere is growing interest in the role of emotion regulation in anorexia nervosa (AN). Although anxiety is also hypothesized to impact symptoms of AN, little is known about how emotion regulation, anxiety, and eating disorder symptoms interact in AN. In this study, we examined the associations between emotion regulation, anxiety, and eating disorder symptom severity in AN.MethodsQuestionnaires and interviews assessing emotion regulation difficulties, anxiety, eating disorder symptoms, and eating disorder-related clinical impairment were collected from group of underweight individuals with AN (n = 59) at admission to inpatient treatment. Hierarchical linear regressions were used to examine the associations of emotion regulation difficulties, anxiety, and the interaction of these constructs with eating disorder symptoms and eating disorder-related clinical impairment.ResultsEmotion regulation difficulties were significantly positively associated with eating disorder symptoms and related clinical impairment only when anxiety levels were low and anxiety was significantly positively associated with eating disorder symptoms and related clinical impairment only when emotion regulation problems were not elevated.ConclusionsThis study adds to a growing literature suggesting that emotion regulation deficits are associated with eating disorder symptoms in AN. Certain individuals with AN may especially benefit from a focus on developing emotion regulation skills in the acute stages of illness.     

Direct and indirect predictors of social anxiety: The role of anxiety sensitivity,behavioral inhibition,experiential avoidance and self-consciousness

Using mediated and moderated regression, this study examined the hypothesis that anxiety sensitivity, the tendency to be concerned about anxiety symptoms, and behavioral inhibition, the tendency to withdraw from novel and potentially dangerous stimuli, predict social anxiety indirectly through experiential avoidance as measured by the Acceptance and Action Questionnaire-II and self-consciousness, as measured by the Self-Consciousness Scale. Behavioral inhibition and anxiety sensitivity are operationalized as temperamental traits, while experiential avoidance and self-consciousness are seen as learned emotion regulation strategies. Study 1 included college student groups from Cyprus scoring high and low on social anxiety (N = 64 and N = 63) as measured by the Social Phobia and Anxiety Inventory. Study 2 examined a random community sample aged 18–65 (N = 324) treating variables as continuous and using the Psychiatric Disorders Screening Questionnaire to screen for social anxiety. Results suggest that experiential avoidance, but not self-consciousness mediates the effects of anxiety sensitivity on predicting social anxiety status, but that behavioral inhibition predicts social anxiety directly and not through the proposed mediators. Moderation effects were not supported. Overall, the study finds that social anxiety symptomatology is predicted not only by behavioral inhibition, but also anxiety sensitivity, when individuals take actions to avoid anxious experiences. Modifying such avoidant coping approaches may be more beneficial for psychological treatments than attempts to change long-standing, temperamental personality traits.     

Self-Injurious Behaviors and Adult Attachment: A Review of the Literature

Self-injurious behaviors (SIB) continue to afflict a significant segment of the clinical and general population, sometimes with fatal consequences. The development of SIB seems to share developmental pathways and mechanisms similar to attachment insecurity. To date, no reviews have explored their relationship. A search of publication databases PubMed and PsychInfo from 1969 through April 2018 was conducted and 17 papers met inclusion criteria. Of the 17 articles identified, 13 reported a positive relationship and 1 reported a negative relationship between attachment insecurity and SIB. Both attachment anxiety and avoidance seem to play a role in the risk for SIB, possibly through different mechanisms and likely with different impacts on the choice for either self-harm or suicide attempts.     

Stress and Mood Disorders During Pregnancy: Implications for Child Development

Recent research suggests that stress, anxiety, and depression during pregnancy may have an impact on how the child develops. In this article, the central literature supporting this hypothesis is reviewed. Next, studies from our laboratory showing that differences in fetal heart rate patterns are associated with women's anxiety and depressive symptomatology are reviewed. The data indicate that we can detect fetal markers associated with alterations in women's mood that also are linked to differences in the neurobiological substrate of the fetus' emerging emotion regulation system. Identifying such fetal character-istics someday may contribute to the early detection and prevention of predispositions to childhood risk for emotional problems and even psychopatholgy.     

Lower body weight is associated with less negative emotions in sad autobiographical memories of patients with anorexia nervosa

Food restriction and weight-loss have been proposed to represent pathogenic mechanisms of emotion regulation in anorexia nervosa (AN). However, there is a lack of studies empirically examining this hypothesis. Therefore, the present study compared 25 women with AN and 25 healthy control women (HC) regarding spontaneous emotional processing of autobiographic memories. Participants' idiographic memories of sad autobiographic events were analyzed using computerized, quantitative text analysis as an unobtrusive approach of nonreactive assessment. Compared to HC, AN patients retrieved more negative but a comparable number of positive emotions. Moreover, the lesser the body weight in AN patients, the lesser negative emotions they retrieved, irrespective of current levels of depressive symptoms and duration of illness. No such association was found in HC. These preliminary findings are in line with models of AN proposing that food restriction and weight-loss may be negatively reinforced by the alleviation of aversive emotional responses.     

Mindfulness and emotion regulation in older and young adults

Objectives: Research shows that dispositional mindfulness is associated with metrics of overall well-being, with enhanced emotion regulation potentially underlying these salutary effects. However, the role of regulation strategy use remains poorly understood. In this study, we examined age-variant associations between dispositional mindfulness, emotion regulation strategies, and emotion dysregulation.

Method: Self-report data were collected from 50 older and 50 young adults on mindfulness, emotion dysregulation, and recent strategy use. For the current study, we examined if cognitive reappraisal, experiential suppression, and thought avoidance use mediated the association between mindfulness and emotion dysregulation.

Results: Thought avoidance, but not reappraisal or suppression strategies, partially mediated the association between mindfulness and emotion dysregulation. Age group moderated the observed mediation, such that for young adults, lower mindfulness was associated with greater use of thought avoidance, and in turn with greater emotion dysregulation (e.g., difficulties engaging in goal-directed behavior in the face of strong emotions).

Conclusion: The current cross-sectional study suggests that reduced avoidance of thoughts may partially explain the relationship between trait mindfulness and enhanced emotion regulation, with this mediational pathway being stronger for young compared with older adults.