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Paper read at Eating Disorders Alpbach 2016
The 24nd International Conference
October 20-22 2016
The integration of attachment interventions into the transdiagnostic cognitive-behavioral treatment
in two eating disorder cases
Tamaacutes Doumlmoumltoumlr SZALAI
Semmelweis University Institute of Behavioural Sciences Budapest Hungary
The 24th International Conference on Eating Disorders Alpbach 22 October 2016
Attachment-based mental representations can mediate between
early experiences and adult psychopathologies (Unoka 2007)
Attachment can be insecure in all EDs (Ward et al 2010)
Attachment security and symptom severity (Broberg et al 2001)
Symptoms influence the proximity of patients and objects hidden attachment dynamics (Orzolek-Kronner 2002)
Vs Mainstream models emphasize biological cultural or cognitive-behavioral aspects without attachment concepts (Tasca amp Balfour 2014)
Introduction Attachment and Eating Disorders
Interpersonal difficulties in the transdiagnostic theory of the maintenance of eating disorders
(Fairburn et al 2003 p 516)
Other factors interact with the maintaining mechanisms and outcomes (Fairburn et al 2003)
Patients with PDs emotion-processing deficits and attachment disturbances respond worse to symptom-focused therapies (Myers et al 2006)
Integrating attachment interventions into evidence-based CBT treatments
Hybrid therapies An unexplored gap of treatment
Can we cognitively operationalize attachment functioning
(Barholomew amp Horowitz 1991 Elliot amp Reis 2003 Mikulincer et al 2003 Tasca amp Balfour 2014)
Aim to test the hypothesized two-level treatment model in two relevant ED cases
Hypothesis 1 attachment and CBT interventions could be integrated to personalized case models and treatments
Hypothesis 2 improvements in attachment functioning would be associated with positive outcomes
Aims and Hypotheses
20-year-old female engineering student (BMI = 205)
High demands her studies and sport career
Symptoms after moving to a dormitory during daytimes she felt unable to eat in her room she was lonely and stressed
Weekly 2-3 binges no compensation mild BED (APA 2013) + critical body checking
No comorbid physical or psychiatric conditions
High perfectionism avoidant attachment
Agreement 1 initial + 10 treamtent sessions + a one-month follow-up
Aim improve her coping with negative moods and interpersonal difficulties to reduce her symptoms
Case 1
32-year-old female bookkeeper (BMI = 203)
Symptoms after her husbandrsquo cheat and a fitness competition
Weekly 4-5 binges + vomiting moderately severe BN (APA 2013)
No somatic complications or psychiatric anamnesis
Extremely critical attitude to body with lacking insight and alexithymia
Insecure strongly ambivalent dependent attachment
Agreement 1 initial 12 treatment sessions + a one-month follow-up
Aim improve emotion regulation interpersonal functioning and control over the symptoms
She complained about her husbandrsquos unresponsiveness + BN episodes were precipitated by interpersonal situations with impaired reflections
Case 2
Graph about the escalation of bulimic symptoms
Transdiagnostic treatment frame four phases for all (BMI gt 175) ED outpatients with regular 1st 2nd and closing stage
Initial session intervention period a one-month follow-up
Each 60-minute session had three stages
1 Food diary mood and symptom changes
2 Weekly experiences and topics based on the case model
3 Summarizing the session and setting homework
Treatment outlines
Self-help recovery guidelines (Cooper 1995 Tuacutery 2005)
Food diary
Normalization of daily meals
Reducing dietary restraint
Reducing over-evaluation of eating shape and weight control
Avoidance of body checking
Modifying maladaptive thoughts related to eating
CBT interventions (Fairburn 1993 2005 2008)
1 phase rapport patient education initial case formulation
2 phase discussion of the first model was excessive control perfectionism and factors influencing emotion regulation self-esteem and interpersonal behavior
Breaks of primary bonds and poor attachment functioning among precipitating and maintaining factors Extended case conceptualizations integrated attachment
Treatment phases
The interaction of attachment functioning with the four cognitive-behavioral factors
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
The integration of attachment interventions into the transdiagnostic cognitive-behavioral treatment
in two eating disorder cases
Tamaacutes Doumlmoumltoumlr SZALAI
Semmelweis University Institute of Behavioural Sciences Budapest Hungary
The 24th International Conference on Eating Disorders Alpbach 22 October 2016
Attachment-based mental representations can mediate between
early experiences and adult psychopathologies (Unoka 2007)
Attachment can be insecure in all EDs (Ward et al 2010)
Attachment security and symptom severity (Broberg et al 2001)
Symptoms influence the proximity of patients and objects hidden attachment dynamics (Orzolek-Kronner 2002)
Vs Mainstream models emphasize biological cultural or cognitive-behavioral aspects without attachment concepts (Tasca amp Balfour 2014)
Introduction Attachment and Eating Disorders
Interpersonal difficulties in the transdiagnostic theory of the maintenance of eating disorders
(Fairburn et al 2003 p 516)
Other factors interact with the maintaining mechanisms and outcomes (Fairburn et al 2003)
Patients with PDs emotion-processing deficits and attachment disturbances respond worse to symptom-focused therapies (Myers et al 2006)
Integrating attachment interventions into evidence-based CBT treatments
Hybrid therapies An unexplored gap of treatment
Can we cognitively operationalize attachment functioning
(Barholomew amp Horowitz 1991 Elliot amp Reis 2003 Mikulincer et al 2003 Tasca amp Balfour 2014)
Aim to test the hypothesized two-level treatment model in two relevant ED cases
Hypothesis 1 attachment and CBT interventions could be integrated to personalized case models and treatments
Hypothesis 2 improvements in attachment functioning would be associated with positive outcomes
Aims and Hypotheses
20-year-old female engineering student (BMI = 205)
High demands her studies and sport career
Symptoms after moving to a dormitory during daytimes she felt unable to eat in her room she was lonely and stressed
Weekly 2-3 binges no compensation mild BED (APA 2013) + critical body checking
No comorbid physical or psychiatric conditions
High perfectionism avoidant attachment
Agreement 1 initial + 10 treamtent sessions + a one-month follow-up
Aim improve her coping with negative moods and interpersonal difficulties to reduce her symptoms
Case 1
32-year-old female bookkeeper (BMI = 203)
Symptoms after her husbandrsquo cheat and a fitness competition
Weekly 4-5 binges + vomiting moderately severe BN (APA 2013)
No somatic complications or psychiatric anamnesis
Extremely critical attitude to body with lacking insight and alexithymia
Insecure strongly ambivalent dependent attachment
Agreement 1 initial 12 treatment sessions + a one-month follow-up
Aim improve emotion regulation interpersonal functioning and control over the symptoms
She complained about her husbandrsquos unresponsiveness + BN episodes were precipitated by interpersonal situations with impaired reflections
Case 2
Graph about the escalation of bulimic symptoms
Transdiagnostic treatment frame four phases for all (BMI gt 175) ED outpatients with regular 1st 2nd and closing stage
Initial session intervention period a one-month follow-up
Each 60-minute session had three stages
1 Food diary mood and symptom changes
2 Weekly experiences and topics based on the case model
3 Summarizing the session and setting homework
Treatment outlines
Self-help recovery guidelines (Cooper 1995 Tuacutery 2005)
Food diary
Normalization of daily meals
Reducing dietary restraint
Reducing over-evaluation of eating shape and weight control
Avoidance of body checking
Modifying maladaptive thoughts related to eating
CBT interventions (Fairburn 1993 2005 2008)
1 phase rapport patient education initial case formulation
2 phase discussion of the first model was excessive control perfectionism and factors influencing emotion regulation self-esteem and interpersonal behavior
Breaks of primary bonds and poor attachment functioning among precipitating and maintaining factors Extended case conceptualizations integrated attachment
Treatment phases
The interaction of attachment functioning with the four cognitive-behavioral factors
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Attachment-based mental representations can mediate between
early experiences and adult psychopathologies (Unoka 2007)
Attachment can be insecure in all EDs (Ward et al 2010)
Attachment security and symptom severity (Broberg et al 2001)
Symptoms influence the proximity of patients and objects hidden attachment dynamics (Orzolek-Kronner 2002)
Vs Mainstream models emphasize biological cultural or cognitive-behavioral aspects without attachment concepts (Tasca amp Balfour 2014)
Introduction Attachment and Eating Disorders
Interpersonal difficulties in the transdiagnostic theory of the maintenance of eating disorders
(Fairburn et al 2003 p 516)
Other factors interact with the maintaining mechanisms and outcomes (Fairburn et al 2003)
Patients with PDs emotion-processing deficits and attachment disturbances respond worse to symptom-focused therapies (Myers et al 2006)
Integrating attachment interventions into evidence-based CBT treatments
Hybrid therapies An unexplored gap of treatment
Can we cognitively operationalize attachment functioning
(Barholomew amp Horowitz 1991 Elliot amp Reis 2003 Mikulincer et al 2003 Tasca amp Balfour 2014)
Aim to test the hypothesized two-level treatment model in two relevant ED cases
Hypothesis 1 attachment and CBT interventions could be integrated to personalized case models and treatments
Hypothesis 2 improvements in attachment functioning would be associated with positive outcomes
Aims and Hypotheses
20-year-old female engineering student (BMI = 205)
High demands her studies and sport career
Symptoms after moving to a dormitory during daytimes she felt unable to eat in her room she was lonely and stressed
Weekly 2-3 binges no compensation mild BED (APA 2013) + critical body checking
No comorbid physical or psychiatric conditions
High perfectionism avoidant attachment
Agreement 1 initial + 10 treamtent sessions + a one-month follow-up
Aim improve her coping with negative moods and interpersonal difficulties to reduce her symptoms
Case 1
32-year-old female bookkeeper (BMI = 203)
Symptoms after her husbandrsquo cheat and a fitness competition
Weekly 4-5 binges + vomiting moderately severe BN (APA 2013)
No somatic complications or psychiatric anamnesis
Extremely critical attitude to body with lacking insight and alexithymia
Insecure strongly ambivalent dependent attachment
Agreement 1 initial 12 treatment sessions + a one-month follow-up
Aim improve emotion regulation interpersonal functioning and control over the symptoms
She complained about her husbandrsquos unresponsiveness + BN episodes were precipitated by interpersonal situations with impaired reflections
Case 2
Graph about the escalation of bulimic symptoms
Transdiagnostic treatment frame four phases for all (BMI gt 175) ED outpatients with regular 1st 2nd and closing stage
Initial session intervention period a one-month follow-up
Each 60-minute session had three stages
1 Food diary mood and symptom changes
2 Weekly experiences and topics based on the case model
3 Summarizing the session and setting homework
Treatment outlines
Self-help recovery guidelines (Cooper 1995 Tuacutery 2005)
Food diary
Normalization of daily meals
Reducing dietary restraint
Reducing over-evaluation of eating shape and weight control
Avoidance of body checking
Modifying maladaptive thoughts related to eating
CBT interventions (Fairburn 1993 2005 2008)
1 phase rapport patient education initial case formulation
2 phase discussion of the first model was excessive control perfectionism and factors influencing emotion regulation self-esteem and interpersonal behavior
Breaks of primary bonds and poor attachment functioning among precipitating and maintaining factors Extended case conceptualizations integrated attachment
Treatment phases
The interaction of attachment functioning with the four cognitive-behavioral factors
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Interpersonal difficulties in the transdiagnostic theory of the maintenance of eating disorders
(Fairburn et al 2003 p 516)
Other factors interact with the maintaining mechanisms and outcomes (Fairburn et al 2003)
Patients with PDs emotion-processing deficits and attachment disturbances respond worse to symptom-focused therapies (Myers et al 2006)
Integrating attachment interventions into evidence-based CBT treatments
Hybrid therapies An unexplored gap of treatment
Can we cognitively operationalize attachment functioning
(Barholomew amp Horowitz 1991 Elliot amp Reis 2003 Mikulincer et al 2003 Tasca amp Balfour 2014)
Aim to test the hypothesized two-level treatment model in two relevant ED cases
Hypothesis 1 attachment and CBT interventions could be integrated to personalized case models and treatments
Hypothesis 2 improvements in attachment functioning would be associated with positive outcomes
Aims and Hypotheses
20-year-old female engineering student (BMI = 205)
High demands her studies and sport career
Symptoms after moving to a dormitory during daytimes she felt unable to eat in her room she was lonely and stressed
Weekly 2-3 binges no compensation mild BED (APA 2013) + critical body checking
No comorbid physical or psychiatric conditions
High perfectionism avoidant attachment
Agreement 1 initial + 10 treamtent sessions + a one-month follow-up
Aim improve her coping with negative moods and interpersonal difficulties to reduce her symptoms
Case 1
32-year-old female bookkeeper (BMI = 203)
Symptoms after her husbandrsquo cheat and a fitness competition
Weekly 4-5 binges + vomiting moderately severe BN (APA 2013)
No somatic complications or psychiatric anamnesis
Extremely critical attitude to body with lacking insight and alexithymia
Insecure strongly ambivalent dependent attachment
Agreement 1 initial 12 treatment sessions + a one-month follow-up
Aim improve emotion regulation interpersonal functioning and control over the symptoms
She complained about her husbandrsquos unresponsiveness + BN episodes were precipitated by interpersonal situations with impaired reflections
Case 2
Graph about the escalation of bulimic symptoms
Transdiagnostic treatment frame four phases for all (BMI gt 175) ED outpatients with regular 1st 2nd and closing stage
Initial session intervention period a one-month follow-up
Each 60-minute session had three stages
1 Food diary mood and symptom changes
2 Weekly experiences and topics based on the case model
3 Summarizing the session and setting homework
Treatment outlines
Self-help recovery guidelines (Cooper 1995 Tuacutery 2005)
Food diary
Normalization of daily meals
Reducing dietary restraint
Reducing over-evaluation of eating shape and weight control
Avoidance of body checking
Modifying maladaptive thoughts related to eating
CBT interventions (Fairburn 1993 2005 2008)
1 phase rapport patient education initial case formulation
2 phase discussion of the first model was excessive control perfectionism and factors influencing emotion regulation self-esteem and interpersonal behavior
Breaks of primary bonds and poor attachment functioning among precipitating and maintaining factors Extended case conceptualizations integrated attachment
Treatment phases
The interaction of attachment functioning with the four cognitive-behavioral factors
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Other factors interact with the maintaining mechanisms and outcomes (Fairburn et al 2003)
Patients with PDs emotion-processing deficits and attachment disturbances respond worse to symptom-focused therapies (Myers et al 2006)
Integrating attachment interventions into evidence-based CBT treatments
Hybrid therapies An unexplored gap of treatment
Can we cognitively operationalize attachment functioning
(Barholomew amp Horowitz 1991 Elliot amp Reis 2003 Mikulincer et al 2003 Tasca amp Balfour 2014)
Aim to test the hypothesized two-level treatment model in two relevant ED cases
Hypothesis 1 attachment and CBT interventions could be integrated to personalized case models and treatments
Hypothesis 2 improvements in attachment functioning would be associated with positive outcomes
Aims and Hypotheses
20-year-old female engineering student (BMI = 205)
High demands her studies and sport career
Symptoms after moving to a dormitory during daytimes she felt unable to eat in her room she was lonely and stressed
Weekly 2-3 binges no compensation mild BED (APA 2013) + critical body checking
No comorbid physical or psychiatric conditions
High perfectionism avoidant attachment
Agreement 1 initial + 10 treamtent sessions + a one-month follow-up
Aim improve her coping with negative moods and interpersonal difficulties to reduce her symptoms
Case 1
32-year-old female bookkeeper (BMI = 203)
Symptoms after her husbandrsquo cheat and a fitness competition
Weekly 4-5 binges + vomiting moderately severe BN (APA 2013)
No somatic complications or psychiatric anamnesis
Extremely critical attitude to body with lacking insight and alexithymia
Insecure strongly ambivalent dependent attachment
Agreement 1 initial 12 treatment sessions + a one-month follow-up
Aim improve emotion regulation interpersonal functioning and control over the symptoms
She complained about her husbandrsquos unresponsiveness + BN episodes were precipitated by interpersonal situations with impaired reflections
Case 2
Graph about the escalation of bulimic symptoms
Transdiagnostic treatment frame four phases for all (BMI gt 175) ED outpatients with regular 1st 2nd and closing stage
Initial session intervention period a one-month follow-up
Each 60-minute session had three stages
1 Food diary mood and symptom changes
2 Weekly experiences and topics based on the case model
3 Summarizing the session and setting homework
Treatment outlines
Self-help recovery guidelines (Cooper 1995 Tuacutery 2005)
Food diary
Normalization of daily meals
Reducing dietary restraint
Reducing over-evaluation of eating shape and weight control
Avoidance of body checking
Modifying maladaptive thoughts related to eating
CBT interventions (Fairburn 1993 2005 2008)
1 phase rapport patient education initial case formulation
2 phase discussion of the first model was excessive control perfectionism and factors influencing emotion regulation self-esteem and interpersonal behavior
Breaks of primary bonds and poor attachment functioning among precipitating and maintaining factors Extended case conceptualizations integrated attachment
Treatment phases
The interaction of attachment functioning with the four cognitive-behavioral factors
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Can we cognitively operationalize attachment functioning
(Barholomew amp Horowitz 1991 Elliot amp Reis 2003 Mikulincer et al 2003 Tasca amp Balfour 2014)
Aim to test the hypothesized two-level treatment model in two relevant ED cases
Hypothesis 1 attachment and CBT interventions could be integrated to personalized case models and treatments
Hypothesis 2 improvements in attachment functioning would be associated with positive outcomes
Aims and Hypotheses
20-year-old female engineering student (BMI = 205)
High demands her studies and sport career
Symptoms after moving to a dormitory during daytimes she felt unable to eat in her room she was lonely and stressed
Weekly 2-3 binges no compensation mild BED (APA 2013) + critical body checking
No comorbid physical or psychiatric conditions
High perfectionism avoidant attachment
Agreement 1 initial + 10 treamtent sessions + a one-month follow-up
Aim improve her coping with negative moods and interpersonal difficulties to reduce her symptoms
Case 1
32-year-old female bookkeeper (BMI = 203)
Symptoms after her husbandrsquo cheat and a fitness competition
Weekly 4-5 binges + vomiting moderately severe BN (APA 2013)
No somatic complications or psychiatric anamnesis
Extremely critical attitude to body with lacking insight and alexithymia
Insecure strongly ambivalent dependent attachment
Agreement 1 initial 12 treatment sessions + a one-month follow-up
Aim improve emotion regulation interpersonal functioning and control over the symptoms
She complained about her husbandrsquos unresponsiveness + BN episodes were precipitated by interpersonal situations with impaired reflections
Case 2
Graph about the escalation of bulimic symptoms
Transdiagnostic treatment frame four phases for all (BMI gt 175) ED outpatients with regular 1st 2nd and closing stage
Initial session intervention period a one-month follow-up
Each 60-minute session had three stages
1 Food diary mood and symptom changes
2 Weekly experiences and topics based on the case model
3 Summarizing the session and setting homework
Treatment outlines
Self-help recovery guidelines (Cooper 1995 Tuacutery 2005)
Food diary
Normalization of daily meals
Reducing dietary restraint
Reducing over-evaluation of eating shape and weight control
Avoidance of body checking
Modifying maladaptive thoughts related to eating
CBT interventions (Fairburn 1993 2005 2008)
1 phase rapport patient education initial case formulation
2 phase discussion of the first model was excessive control perfectionism and factors influencing emotion regulation self-esteem and interpersonal behavior
Breaks of primary bonds and poor attachment functioning among precipitating and maintaining factors Extended case conceptualizations integrated attachment
Treatment phases
The interaction of attachment functioning with the four cognitive-behavioral factors
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Aim to test the hypothesized two-level treatment model in two relevant ED cases
Hypothesis 1 attachment and CBT interventions could be integrated to personalized case models and treatments
Hypothesis 2 improvements in attachment functioning would be associated with positive outcomes
Aims and Hypotheses
20-year-old female engineering student (BMI = 205)
High demands her studies and sport career
Symptoms after moving to a dormitory during daytimes she felt unable to eat in her room she was lonely and stressed
Weekly 2-3 binges no compensation mild BED (APA 2013) + critical body checking
No comorbid physical or psychiatric conditions
High perfectionism avoidant attachment
Agreement 1 initial + 10 treamtent sessions + a one-month follow-up
Aim improve her coping with negative moods and interpersonal difficulties to reduce her symptoms
Case 1
32-year-old female bookkeeper (BMI = 203)
Symptoms after her husbandrsquo cheat and a fitness competition
Weekly 4-5 binges + vomiting moderately severe BN (APA 2013)
No somatic complications or psychiatric anamnesis
Extremely critical attitude to body with lacking insight and alexithymia
Insecure strongly ambivalent dependent attachment
Agreement 1 initial 12 treatment sessions + a one-month follow-up
Aim improve emotion regulation interpersonal functioning and control over the symptoms
She complained about her husbandrsquos unresponsiveness + BN episodes were precipitated by interpersonal situations with impaired reflections
Case 2
Graph about the escalation of bulimic symptoms
Transdiagnostic treatment frame four phases for all (BMI gt 175) ED outpatients with regular 1st 2nd and closing stage
Initial session intervention period a one-month follow-up
Each 60-minute session had three stages
1 Food diary mood and symptom changes
2 Weekly experiences and topics based on the case model
3 Summarizing the session and setting homework
Treatment outlines
Self-help recovery guidelines (Cooper 1995 Tuacutery 2005)
Food diary
Normalization of daily meals
Reducing dietary restraint
Reducing over-evaluation of eating shape and weight control
Avoidance of body checking
Modifying maladaptive thoughts related to eating
CBT interventions (Fairburn 1993 2005 2008)
1 phase rapport patient education initial case formulation
2 phase discussion of the first model was excessive control perfectionism and factors influencing emotion regulation self-esteem and interpersonal behavior
Breaks of primary bonds and poor attachment functioning among precipitating and maintaining factors Extended case conceptualizations integrated attachment
Treatment phases
The interaction of attachment functioning with the four cognitive-behavioral factors
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
20-year-old female engineering student (BMI = 205)
High demands her studies and sport career
Symptoms after moving to a dormitory during daytimes she felt unable to eat in her room she was lonely and stressed
Weekly 2-3 binges no compensation mild BED (APA 2013) + critical body checking
No comorbid physical or psychiatric conditions
High perfectionism avoidant attachment
Agreement 1 initial + 10 treamtent sessions + a one-month follow-up
Aim improve her coping with negative moods and interpersonal difficulties to reduce her symptoms
Case 1
32-year-old female bookkeeper (BMI = 203)
Symptoms after her husbandrsquo cheat and a fitness competition
Weekly 4-5 binges + vomiting moderately severe BN (APA 2013)
No somatic complications or psychiatric anamnesis
Extremely critical attitude to body with lacking insight and alexithymia
Insecure strongly ambivalent dependent attachment
Agreement 1 initial 12 treatment sessions + a one-month follow-up
Aim improve emotion regulation interpersonal functioning and control over the symptoms
She complained about her husbandrsquos unresponsiveness + BN episodes were precipitated by interpersonal situations with impaired reflections
Case 2
Graph about the escalation of bulimic symptoms
Transdiagnostic treatment frame four phases for all (BMI gt 175) ED outpatients with regular 1st 2nd and closing stage
Initial session intervention period a one-month follow-up
Each 60-minute session had three stages
1 Food diary mood and symptom changes
2 Weekly experiences and topics based on the case model
3 Summarizing the session and setting homework
Treatment outlines
Self-help recovery guidelines (Cooper 1995 Tuacutery 2005)
Food diary
Normalization of daily meals
Reducing dietary restraint
Reducing over-evaluation of eating shape and weight control
Avoidance of body checking
Modifying maladaptive thoughts related to eating
CBT interventions (Fairburn 1993 2005 2008)
1 phase rapport patient education initial case formulation
2 phase discussion of the first model was excessive control perfectionism and factors influencing emotion regulation self-esteem and interpersonal behavior
Breaks of primary bonds and poor attachment functioning among precipitating and maintaining factors Extended case conceptualizations integrated attachment
Treatment phases
The interaction of attachment functioning with the four cognitive-behavioral factors
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
32-year-old female bookkeeper (BMI = 203)
Symptoms after her husbandrsquo cheat and a fitness competition
Weekly 4-5 binges + vomiting moderately severe BN (APA 2013)
No somatic complications or psychiatric anamnesis
Extremely critical attitude to body with lacking insight and alexithymia
Insecure strongly ambivalent dependent attachment
Agreement 1 initial 12 treatment sessions + a one-month follow-up
Aim improve emotion regulation interpersonal functioning and control over the symptoms
She complained about her husbandrsquos unresponsiveness + BN episodes were precipitated by interpersonal situations with impaired reflections
Case 2
Graph about the escalation of bulimic symptoms
Transdiagnostic treatment frame four phases for all (BMI gt 175) ED outpatients with regular 1st 2nd and closing stage
Initial session intervention period a one-month follow-up
Each 60-minute session had three stages
1 Food diary mood and symptom changes
2 Weekly experiences and topics based on the case model
3 Summarizing the session and setting homework
Treatment outlines
Self-help recovery guidelines (Cooper 1995 Tuacutery 2005)
Food diary
Normalization of daily meals
Reducing dietary restraint
Reducing over-evaluation of eating shape and weight control
Avoidance of body checking
Modifying maladaptive thoughts related to eating
CBT interventions (Fairburn 1993 2005 2008)
1 phase rapport patient education initial case formulation
2 phase discussion of the first model was excessive control perfectionism and factors influencing emotion regulation self-esteem and interpersonal behavior
Breaks of primary bonds and poor attachment functioning among precipitating and maintaining factors Extended case conceptualizations integrated attachment
Treatment phases
The interaction of attachment functioning with the four cognitive-behavioral factors
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Graph about the escalation of bulimic symptoms
Transdiagnostic treatment frame four phases for all (BMI gt 175) ED outpatients with regular 1st 2nd and closing stage
Initial session intervention period a one-month follow-up
Each 60-minute session had three stages
1 Food diary mood and symptom changes
2 Weekly experiences and topics based on the case model
3 Summarizing the session and setting homework
Treatment outlines
Self-help recovery guidelines (Cooper 1995 Tuacutery 2005)
Food diary
Normalization of daily meals
Reducing dietary restraint
Reducing over-evaluation of eating shape and weight control
Avoidance of body checking
Modifying maladaptive thoughts related to eating
CBT interventions (Fairburn 1993 2005 2008)
1 phase rapport patient education initial case formulation
2 phase discussion of the first model was excessive control perfectionism and factors influencing emotion regulation self-esteem and interpersonal behavior
Breaks of primary bonds and poor attachment functioning among precipitating and maintaining factors Extended case conceptualizations integrated attachment
Treatment phases
The interaction of attachment functioning with the four cognitive-behavioral factors
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Transdiagnostic treatment frame four phases for all (BMI gt 175) ED outpatients with regular 1st 2nd and closing stage
Initial session intervention period a one-month follow-up
Each 60-minute session had three stages
1 Food diary mood and symptom changes
2 Weekly experiences and topics based on the case model
3 Summarizing the session and setting homework
Treatment outlines
Self-help recovery guidelines (Cooper 1995 Tuacutery 2005)
Food diary
Normalization of daily meals
Reducing dietary restraint
Reducing over-evaluation of eating shape and weight control
Avoidance of body checking
Modifying maladaptive thoughts related to eating
CBT interventions (Fairburn 1993 2005 2008)
1 phase rapport patient education initial case formulation
2 phase discussion of the first model was excessive control perfectionism and factors influencing emotion regulation self-esteem and interpersonal behavior
Breaks of primary bonds and poor attachment functioning among precipitating and maintaining factors Extended case conceptualizations integrated attachment
Treatment phases
The interaction of attachment functioning with the four cognitive-behavioral factors
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Self-help recovery guidelines (Cooper 1995 Tuacutery 2005)
Food diary
Normalization of daily meals
Reducing dietary restraint
Reducing over-evaluation of eating shape and weight control
Avoidance of body checking
Modifying maladaptive thoughts related to eating
CBT interventions (Fairburn 1993 2005 2008)
1 phase rapport patient education initial case formulation
2 phase discussion of the first model was excessive control perfectionism and factors influencing emotion regulation self-esteem and interpersonal behavior
Breaks of primary bonds and poor attachment functioning among precipitating and maintaining factors Extended case conceptualizations integrated attachment
Treatment phases
The interaction of attachment functioning with the four cognitive-behavioral factors
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
1 phase rapport patient education initial case formulation
2 phase discussion of the first model was excessive control perfectionism and factors influencing emotion regulation self-esteem and interpersonal behavior
Breaks of primary bonds and poor attachment functioning among precipitating and maintaining factors Extended case conceptualizations integrated attachment
Treatment phases
The interaction of attachment functioning with the four cognitive-behavioral factors
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
The interaction of attachment functioning with the four cognitive-behavioral factors
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Insight on non-reflected knowledge on concepts of self and others
Identifying maladaptive chain-reactions graph about the symptoms
Modifying attachment-related automatic thoughts other explanations
Improving mentalization and interpesonal reflective skills social diary
Supporting self-esteem sources of self-acceptance differentiating personal value from achievements and self-appraisal from othersrsquo attitudes
Improving mood regulation cues of distress and comforting activities
Counteracting dehyper-activated distress-reducing strategies
3rd phase of treatment Assessment of attachment functioning and
attachment interventions
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Closing phase personal risk and protective factors to prevent relapses and ensure progress
Treatment phases
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Symptoms after breaks of primary bonds
Negative self-concept low self-esteem
Need for external reinforcement
Low distress tolerance
Interpersonal sensitivity
Impaired reflective functioning
Low awareness of attachment-related behaviors
Discussion Similarities of the cases
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Differences of the cases
Case 1 Moderate BED less impulsive better personality organization more reflective Perfectionism decreased self-esteem and mood regulation improved Decreased tendency for avoidance but active social life and good insight into her interpersonal behavior Counteracted her tendencies to respond to distress with avoidance Symptoms ceased with one-month follow-up
Case 2
Moderately severe BN worse personality organization emotion regulation and reflective capability
She gained insight into the consequences of her behavior her mood regulation improved
Little improvement in interpersonal reflective functions
Not able entirely to overcome her dependency and hyper-activation
More secure less ambivalent attachment better body image but relapses about once a month
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Improvement in attachment-functioning reflective skills and reduction in attachment anxiety positive outcomes (Maxwell et al 2014 Tasca et al 2011 2013)
Categorical diagnosis + dimensional description of personality and attachment functioning (Illing et al 2010 Tasca et al 2009)
Attention to attachment anxiety preoccupation or avoidance of relationships need for approval mood regulation and reflective functions (Roberts et al 1996 Tasca amp Balfour 2014)
Attachment interventions in eating disorders
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Four key attachment interventions applied in the cases
(Roberts et al 1996 Illing et al 2010 Tasca et al 2011 2013 Tasca amp Balfour 2014)
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
A theoretical model was tested with only two patients
No anorexia or EDNOS patients were involved
Case studies cannot fully assure the methodological grounding
Treatments were relatively short
Improvements in interpersonal reflections self-appraisal mood regulation and counteracting attachment functioning can be rather suspected then the corrections of the IWM
Generalizability of the findings and the test of the efficacy of the model is limited
Limitations
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
No previous research integrated attachment interventions into a mainly cognitive-behavioral ED treatment
When attachment disturbances contribute to precipitating or maintaining symptoms multilevel treatment shall be offered targeting both the key aspects of attachment functioning and the cognitive-behavioral maintaining factors
Randomized controlled intervention-baesd studies are required to establish the efficacy and determine indications
Conclusions
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
American Psychiatric Association APA (2013) Diagnostic and statistical manual of mental disorders ndash Fifth edition DSM-V Arlington American Psychiatric Publishing Bartholomew K amp Horowitz LM (1991) Attachment styles among young adults a test of a four-category model Journal of Personality and Social Psychology 61(2) 226ndash244 Bartholomew K amp Shaver PR (1998) Methods of assessing adult attachment In JA Simpson amp WS Rholes (Eds) Attachment theory and close relationships (25ndash45) New York The Guilford Press Broberg AG Hjalmers I amp Nevonen L (2001) Eating disorders attachment and interpersonal difficulties a comparison between 18- to 24-year-old patients and normal controls European Eating Disorders Review 9(6) 381ndash396 Buist KL Dekovic M Meeus W amp van Aken MAG (2002) Developmental patterns in adolescent attachment to mother father and sibling Journal of Youth and Adolescence 31(3) 167ndash176 Collins NL amp Read SJ (1990) Adult attachment working models and relationship quality in dating couples Journal of Personality and Social Psychology 58(4) 644ndash663 Cooper PJ (1995) Bulimia nervosa amp binge-eating a guide to recovery New York University Press Elgin J amp Pritchard M (2006) Adult attachment and disordered eating in undergraduate men and women Journal of College Student Psychotherapy 21(2) 25ndash40 Fairburn CG (2005) Cognitive-behavioral therapy for bulimia nervosa In CG Fairburn amp KD Brownell (Eds) Eating disorders and obesity A comprehensive handbook (302-307) New York The Guilford Press Fairburn CG (2008) Cognitive behavior therapy and eating disorders New York Guilford Press Fairburn CG (1997) Interpersonal therapy for bulimia nervosa In DM Garner amp PE Garfinkel (Eds) Handbook of Treatment for Eating Disorders (67-93) New York Guilford Press Fairburn CG Cooper Z amp Shafran R (2003) Cognitive behaviour therapy for eating disorders A transdiagnostic theory and treatment Behaviour Research and Therapy 41(5) 509ndash528 Fairburn CG Marcus MD amp Wilson GT (1993) Cognitive-behavioral therapy for binge eating and bulimia nervosa a comprehensive treatment manual In CG Fairburn amp GT Wilson (Eds) Binge Eating Nature Assessment and Treatment (361-404) New York Guilford Press Griffin D amp Bartholomew K (1994) Models of the self and others fundamental dimensions underlying measures of adult attachment Journal of Personality and Social Psychology 67(3) 430ndash445 Keating L Tasca GA amp Hill R (2013) Structural relationships among attachment insecurity alexithymia and body esteem in women with eating disorders Eating Behaviour 14(3) 366ndash373
References
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Maunder RG amp Hunter JJ (2008) Attachment relationships as determinants of physical health The Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry 36(1) 11ndash32 Maxwell H Tasca GA Ritchie K Balfour L amp Bissada H (2014) Change in attachment insecurity is related to improved outcomes 1-year post group therapy in women with binge eating disorder Psychotherapy 51(1) 57ndash65 Mikulincer M Shaver PR amp Pereg D (2003) Attachment theory and affect regulation The dynamics development and cognitive consequences of attachment-related strategies Motivation and Emotion 27 77ndash102 Orzolek-Kronner C (2002) The effect of attachment theory in the development of eating disorders can symptoms be proximity-seeking Child and Adolescence Social Work Journal 19(6) 421ndash435 Riggs SA amp Jacobvitz D (2002) Expectant parents representations of early attachment relationships associations with mental health and family history Journal of Consulting and Clinical Psychology 70(1) 195ndash204 Roberts JE Gotlib IH amp Kassel JD (1996) Adult Attachment Security and Symptoms of Depression The mediating roles of dysfunctional attitudes and low self-esteem Journal of Personality and Social Psychology 70(2) 310ndash320 Tasca GA amp Balfour L (2014) Eating Disorders and Attachment A Contemporary Psychodynamic Perspective Psychodynamic Psychiatry 42(2) 257ndash276 Tasca GA Ritchie K amp Balfour L (2011) Implications of attachment theory and research for the assessment and treatment of eating disorders Psychotherapy 48(3) 249ndash259 Tasca GA Ritchie K Zachariades F Prolux G Trinneer A Balfour L et al (2013) Attachment insecurity mediates the relationship between childhood trauma and eating disorder psychopathology in a clinical sample A structural equation model Child Abuse amp Neglect 37(11) 926ndash933 Tuacutery F (2005) Anorexia eacutes bulimia Oumlnsegiacutető eacutes csalaacutedsegiacutető kalauz [Anorexia and bulimia Self-help book for patients and relatives] Budapest Print-X Unoka Zs (2007) Szemeacutelyiseacutegvonaacutesok tldquonetdimenzioacutek rossz szldquolői baacutenaacutesmoacuted vizsgaacutelata eacutes laacutetens seacuteruumlleacutekenyseacutegdimenzioacutek azonosiacutetaacutesa egyes pszicheacutes zavarokban [Identifying personality traits symptom dimensions bad early parental treatment and latent vulnerability dimensions in certain psychic disorders] Budapest Semmelweis University Ward A Ramsay R Treasure J (2010) Attachment research in eating disorders British Journal of Medical Psychology 73(1) 35ndash51 Zachrisson HD amp Skaringrderud F (2010) Feelings of insecurity Review of attachment and eating disorders European Eating Disorders Review 18(2) 97ndash106
References
Thank you for your kind attention
szalaidomotorgmailcom
Thank you for your kind attention
szalaidomotorgmailcom
