1. Antonia Bifulco Professor of Lifespan Psychology & Social Science Kingston University BPS Conference April 2013 1 Attachment style and depression in adults: Using a lifespan model

2. An Attachment approach (Bowlby, 1969-80 Attachment and Loss trilogy) 12/10/2014 BPS Conference April 2013 2 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.

3. Attachment style assessment is a powerful tool for psychologists 12/10/2014 BPS Conference April 2013 3 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 12/10/2014 BPS Conference April 2013 4 Major Depression or anxiety onset Neglect or Abuse <17 Insecure Attachment Style in adults Mediating effect Social factors Biological factors Psychological factors

5. Intensive study of London women 12/10/2014 5 Study aims 1. Insecure attachment style will relate to emotional disorder in women 2. Childhood neglect/abuse will relate to insecure attachment style. 3. Insecure style will act as a mediator 4. 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.

6. 10/12/2014 6 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 (Kappa=0.80 correlation London study; Kappa=0.70 EU study) 6 Bifulco, Moran, Ball & Bernazzani (2002)Adult Attachment Style: Its Relationship to clinical depression, SPPE 37; 50-59

7. 10/12/2014 7 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

8. Attachment styles relate to survival strategies of fight, flight, cling and hide 12/10/2014 BPS Conference April 2013 8 Enmeshed styles ‘cling Fearful styles ‘run’ Angry-dismissive styles fight Withdrawn styles ‘hide’ Secure styles seek help

9. Measures - Clinical, SCID for DSM-IV 12/10/2014 9 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

10. Childhood Experience of Care and Abuse (CECA) Bifulco A & Moran P (1998) Wednesday’s Child. Research into women’s experience of neglect and abuse in childhood, and adult depression. Routledge, London 10 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

11. Finding 1 – Attachment style & Depression (N=303, interview 1) 11 % major depression in 12 months Insecure attachment Odds -ratio WalddfP< Highly Enmeshed 5.8310.6510.001 Highly Fearful3.648.7210.003 Highly Angry- dismissive 5.0111.8010.0006 Highly Withdrawn 2.021.541NS Mildly insecure style 1.220.301NS Goodness of fit 78.3% Controls made for depression at point of interview

12. Childhood adversity, attachment style and depression Major Depression Neglect or Abuse <17 Highly insecure Attachment Style*.28.32 Childhood adversity index was double in women with insecure style: 58% vs 29%. p<.001 X Neglect/ Abuse<17 M –Insecure attachment style* Y MDD at follow-up a= 4.53 p<.0001 b=2.30 p<.00001 c= 1.77, NS *Withdrawn style excluded Mediation shown

13. Attachment style and depression – specificity (Loglinear analysis) Major Depression Highly Enmeshed Highly Fearful Highly Angry- dismissive Highly Withdrawn.23.19.26 ns Neglect or Abuse <17.19.28 ns Mediation confirmed for Fearful and Angry-dismissive style

14. Finding 2: Type of attachment style and anxiety disorder in follow-up (N=154) Attachment style interview 1 Anxiety disorder GADSocial Phobia Panic/ Agora EnmeshedNS Fearful0.16*NS0.21**NS Angry-dismissive0.17**0.18*NS WithdrawnNS *p<.01, **,001, ***.0001

15. Mediating role of attachment style- Case Anxiety Case Anxiety Follow-up Interview 1--------------------Interview 2 Neglect or Abuse in childhood Highly insecure Attachment Style*.33 X Neglect/ Abuse<17 M – Insecure attachment style Y Case Anxiety F-u a= 4.53 p<.0001 b=3.28 p<.00001 c= 1.367, NS Mediation confirmed *Withdrawn style excluded

16. Antipathy Neglect Role reversal Physical Sexual Psychological Enmeshed Fearful Angry-dismissive Withdrawn.15*.20**.19**.14*.17*.12*.14* * p<.05, ** p<.01 CECA ASI styles Lack of Care Abuse Specificity - childhood experience and attachment style

17. Severe Lack of care (Antipathy or Neglect Or Role Reversal Severe Abuse (Physical, Sexual or Psychological) Anxious style (Enmeshed or Fearful) Angry-Dismissive style OR=4.19* OR=4.51* OR= significant odds ratios taken from binary logistic regression analyses. *p<.05 ASI CECA  Bifulco & Thomas (2012) Understanding adult attachment in family relationships: Research, Assessment, Intervention. Routledge, London. Childhood experiences and style – regression analyses

18. Implications 10/12/2014 18 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.

19. antonia.bifulco@kingston.ac.uk 12/10/2014 BPS Conference April 2013 19 Thank you for your attention