In this study I explored whether the way adults think about their early childhood is related to their perception of control, coping strategies, and health outcomes. The participants (N=78) in this study were administered the Adult Attachment Interview (AAI) between 1 and 18 years ago, when they were new parents. The current online survey assessed perceived control (a composite of the Perceived Health Competency Scale and a general life control item), coping strategies (generated from a factor analysis of the Brief C.O.P.E. measure), anxiety (GAD-7), overweight (a composite of waist-to-hip ratio by body mass index), lifetime number of mental health diagnoses, and lifetime number of physical health diagnoses. As expected, non-problem-focused coping strategies and low perceived control were significantly associated with overweight and poor mental and physical health outcomes. This study added a developmental component to explain the roots of these maladaptive strategies: Dismissing speech on the AAI, characterized by idealizing childhood, minimizing childhood needs and/or distress, and emphasizing the normalcy and independence of one's upbringing strongly negatively predicted current perceived control and approach coping, relative to Secure speech. In fact, Dismissing speakers endorsed using fewer coping strategies over all. Given the pervasive influence of perceived control and active coping on myriad aging and health outcomes, the origins of these strengths is of particular interest. Dismissing speakers, although they endorse experiencing less anxiety, are clearly faring the worst. Attachment theory as a framework for explaining lifespan agency, anxiety, health behaviors, and outcomes is discussed. / text

Studies of attachment in the community suggest that most people have secure attachment styles, but as many as 40% may have an insecure attachment style (Bakermans-Kranenburg & van Ijzendoorn 2009). Frightening parental behaviour has been found to predict disorganised attachment in infants, which in turn is associated with clinical disturbance in adolescence (Van Ijzendoorn, Schuengel & Bakermans-Kranenburg, 1999). Insecure attachment has been found to be disproportionately more common in many psychiatric disorders than the general population: including substance misuse, eating disorders, and Personality Disorder (PD). Transgenerational transmission of attachment has become widely researched over recent years and evidence has shown that a mother's attachment style can predict the attachment style of her infant (Ward, Ramsay, Turnbull, Steele, Steele, & Treasure, 2001). Research has found that a mothers' ability to mentalize about her own early attachment relationships has important implications in her transition to becoming a mother. Motherhood can be challenging for mothers who have good mental health, therefore women with poor mental health may find the transition to motherhood especially stressful. The aim of the current study was to give voice to mothers who have been silenced in many ways, to learn from their struggles and to help services develop more effective ways to reach 'hard to reach' vulnerable mothers. The Adult Attachment Interview (AAI; George, Kaplan, & Main, 1984) was conducted with eight mothers who were attending a Mentalization-Based Treatment (MBT; Bateman & Fonagy, 2004) group designed for mothers who had caused harm to their children and had subsequently had them removed from their care. Thematic Analysis was used to analyse the AAI transcripts and five main themes emerged: 'Love and loss', 'Change and confusion', 'Families and normality', 'Safety and boundaries' and 'Strength and vulnerability'. The findings contribute to the field of maternal mental health research and clinical implications are discussed at an individual, organisational and societal level.

Hintergrund und Fragestellungen: Panikstörung und Agoraphobie zählen zu den verbreitetsten Angststörungen. Trotz leitliniengerechter Therapie profitieren ca. ein Drittel der Patienten nicht oder es kommt zu Rezidiven. Daher ist es umso wichtiger Faktoren zu finden, die einen Einfluss auf die Therapie haben und das Therapieergebnis vorhersagen könnten. Erkenntnisse der von John Bowlby entwickelten Bindungstheorie können hierbei genutzt werden. In der vorliegenden Arbeit wurde der prädiktive Einfluss von Bindungsmustern auf das Therapieoutcome bei Patienten mit der Primärdiagnose einer Panikstörung und/oder Agoraphobie untersucht. Aus bisherigen Studien ist bekannt, dass Patienten mit psychischen Störungen eine unsicherere Bindung haben als gesunde Kontrollprobanden. Zudem sollen bindungssichere Patienten besser von Psychotherapie profitieren. Allerdings gibt es auch Studien, die keine Zusammenhänge zwischen Bindungssicherheit und Therapieerfolg feststellten, so dass die Befunde insgesamt wenig eindeutig bleiben. Ursachen für diese widersprüchlichen Ergebnisse könnten sein, dass in den bisherigen Untersuchungen oft unterschiedliche Störungsbilder und die verschiedensten Therapieformen bzw. -settings vermischt sowie unterschiedliche Instrumente (Selbst- vs. Fremdeinschätzungsverfahren) zur Erfassung der Bindung genutzt wurden. Fraglich bleibt auch, ob der Einfluss der Bindung nur bei psychodynamischen Therapien zum Tragen kommt. Da der Goldstandard bei der Behandlung von Patienten mit Panikstörung bzw. Agoraphobie die Kognitive Verhaltenstherapie mit Fokus auf Konfrontationen ist, ist es umso wichtiger den Einfluss der Bindung bei dieser Therapieform zu untersuchen. Zudem zeigte sich, dass die Passung von Patient und Therapeut eine wichtige Rolle in der Therapie spielt. Allerdings ist die aktuelle Studienlage zur Passung hinsichtlich von Bindungsmerkmalen dürftig. Bisher wurden nur wenige Untersuchungen im tatsächlich klinisch-therapeutischen Kontext durchgeführt und es fehlen Studien, die den Einfluss der Bindungspassung auf die Symptomreduktion fokussieren. Die genannten methodischen Kritikpunkte bisheriger Studien wurden in der vorliegenden Dissertationsschrift berücksichtigt, um folgende Fragen zu beantworten: Unterscheiden sich Patienten mit einer Panikstörung und/oder Agoraphobie von gesunden Probanden mit vergleichbarem Alter, Geschlecht und Bildungsgrad hinsichtlich ihres Bindungsstils bzw. der Bindungsrepräsentation? Wie wirkt die durchgeführte, leitliniengerechte Therapie bei den Patienten kurz- und langfristig? Gibt es einen Zusammenhang zwischen dem Bindungsstil bzw. der Bindungsrepräsentation der Patienten und dem Therapieergebnis zum Therapieende, drei Monate bzw. ein Jahr nach Therapieende? Und welchen Einfluss hat die bindungsbezogene Patienten-Therapeuten-Passung auf das Therapieergebnis? Methoden: Es wurden 175 Patienten mit einer primären Panikstörung und/oder Agoraphobie sowie 143 gesunde Kontrollpersonen rekrutiert. Bei allen Probanden wurde mittels standardisierter Diagnostik das Vorliegen von Persönlichkeitsstörungen und verschiedenen anderen psychischen Störungen ausgeschlossen. Anschließend nahmen 103 Patienten die gleiche fünfwöchige Behandlung in der Angst-Tagesklinik der Klinik für Psychotherapie und Psychosomatik des Universitätsklinikums Dresden auf. Die behandelnden Therapeuten nahmen ebenfalls an der Untersuchung teil. Bei allen Probanden wurden die Bindungsrepräsentation (Fremdrating) mittels Adult Attachment Interview (AAI) sowie der Bindungsstil (Selbstbeurteilung) mittels Adult Attachment Scale und Bielefelder Fragebogen zu Partnerschaftserwartungen bzw. Klientenerwartungen erfasst. Zur Evaluation des Therapieergebnisses wurde zu Therapiebeginn (t1), Therapieende (t2) sowie zur 3-Monats- (t3) und 1-Jahreskatamnese (t4) die Depressionsschwere erhoben und die allgemeine psychische Belastung mittels des sogenannten GSI-Werts (global severity index) bestimmt. Außerdem wurde die angstspezifische Symptomatik mit verschiedenen Fragebögen zu körperbezogenen Ängsten, Kognitionen und agoraphober Vermeidung allein und in Begleitung erfasst. Ergebnisse: Erwartungskonform zeigten die Patienten sowohl bei den Selbstbeurteilungsinstrumenten als auch dem AAI eine unsicherere Bindung als die gesunden Kontrollprobanden. Die Unterschiede erreichten kleine Effekte bei der kategorialen Unterscheidung und kleine bis mittlere Effektstärken bei der Unterscheidung nach Bindungsskalen. Die Patienten zeigten im AAI vorrangig eine desorganisierte Bindungsrepräsentation, gefolgt von einer unsicher-distanzierten Bindung. Hypothesenkonform nahmen die Angstsymptomatik, die depressive sowie die allgemeine psychische Symptomatik zum Therapieende ab. Die Effektstärken lagen im mittleren bis hohen Bereich. Zudem blieben die Effekte in allen Therapieoutcomemaßen stabil bzw. verbesserten sich sogar zwischen Therapieende und 1-Jahreskatamnese. Zum Einfluss der Bindungsrepräsentation der Patienten auf das Therapieoutcome zeigten sich lediglich bei der agoraphoben Vermeidung zu den Katamnesezeitpunkten einzelne Trends, vorrangig für die AAI-Skala distanziert-verstrickt. Allerdings zeigten sich hypothesenkonforme Zusammenhänge zwischen einem unsichereren Bindungsstil (gekennzeichnet durch niedrige Öffnungsbereitschaft, hohe Akzeptanzprobleme und ein niedriges Zuwendungsbedürfnis) und einem höheren GSI-Wert zu t3. Darüber hinaus sagten höhere Akzeptanzprobleme und ein geringeres Zuwendungsbedürfnis eine stärkere agoraphobe Vermeidung allein zu t3 vorher. Höhere Akzeptanzprobleme gingen außerdem mit einer stärkeren Vermeidung in Begleitung zu t3 und t4 einher. Da am Ende der Untersuchung nur sieben Therapeuten in die Studie eingeschlossen wurden und diese zudem eine überwiegend sichere Bindung sowohl im AAI als auch in den Fragebögen zeigten, haben die Ergebnisse zur Patienten-Therapeuten-Passung rein explorativen Charakter. Für die AAI-Skala distanziert-verstrickt zeigten sich einige signifikante Zusammenhänge mit den Symptombereichen körperbezogene Ängste, Vermeidung und allgemeine psychische Belastung. Allerdings können diese lediglich als Trends bewertet werden, da die standardisierten Regressionsgewichte sehr gering ausfielen. Die Ergebnisse deuten darauf hin, dass eine verstricktere Bindung des Patienten in Kombination mit einem vermeidend gebundenen Therapeuten mit einem schlechteren Therapieoutcome einhergeht. Auch beim Bindungsstil zeigten sich lediglich Trends für die körperbezogenen Ängste und die agoraphobe Vermeidung allein: Je unähnlicher sich Patient und Therapeut hinsichtlich der Skala Akzeptanzprobleme waren, umso schlechter war das Therapieoutcome zur 3-Monats- bzw. 1-Jahreskatamnese. Zudem war die Vermeidung allein zur 3-Monatskatamnese umso höher, je unähnlicher sich beide hinsichtlich der Skala Zuwendungsbedürfnis waren. Schlussfolgerung: Zusammenfassend zeigte die Untersuchung, dass die Patienten eine unsicherere Bindung hatten als die gesunden Kontrollprobanden, die Therapie sehr gut gewirkt hat und dass der Bindungsstil der Patienten einen geringen prädiktiven Einfluss auf das Therapieoutcome hatte. Die Bindungsrepräsentation der Patienten zeigte dagegen keinen bedeutsamen Einfluss. Ebenso hatte die explorativ untersuchte bindungsbezogene Patient-Therapeuten-Passung kaum bedeutsame Vorhersagekraft für das Therapieergebnis. Eine höhere Symptomatik zu Therapiebeginn sagte dagegen bei allen Symptomschweremaßen ein schlechteres Therapieergebnis vorher. Die Bindungsmerkmale scheinen vorrangig beim agoraphoben Vermeidungsverhalten und erst zu den Katamnesezeitpunkten einen Einfluss zu haben. Dabei deuteten vor allem höhere Akzeptanzprobleme und eine verstrickte Bindungsrepräsentation auf ein schlechteres Therapieoutcome hin. Die Frage bezüglich des Einflusses der Passung konnte aufgrund der geringen Therapeuten-Stichprobe nur bedingt geklärt werden. Dennoch lohnt es sich, in diesem Hinblick weiter zu forschen und die vorliegenden Ergebnisse an einer größeren Stichprobe zu replizieren. Die gefundenen geringen Zusammenhänge hinsichtlich der AAI-Skala distanziert-verstrickt deuten darauf hin, dass die Passung möglicherweise erst bei der Kombination eines unsicher gebundenen Patienten mit einem unsicher gebundenen Therapeuten zum Tragen kommt. In zukünftigen Untersuchungen sollte sich daher vor allem auf die spezifischere Unterscheidung nach verstrickter bzw. distanzierter Bindung fokussiert werden.:Inhaltsverzeichnis I Abbildungsverzeichnis IV Tabellenverzeichnis V Abkürzungsverzeichnis VII 1 Einleitung 1 2 Theoretischer Hintergrund 4 2.1 Panikstörung und Agoraphobie 4 2.1.1 Leitsymptomatik 4 2.1.2 Epidemiologie und Verlauf 4 2.1.3 Ätiologie 6 2.1.4 Behandlung 10 2.2 Grundlagen der Bindungstheorie 12 2.2.1 Definition und Entwicklung von Bindung 12 2.2.2 Erfassung von Bindungsrepräsentationen und Bindungsstilen 13 2.3 Bindung und Angststörungen 18 2.4 Bindungsaspekte im Psychotherapieprozess 23 2.4.1 Therapeutische Beziehung als Bindungsbeziehung 23 2.4.2 Bindungsmerkmale der Patienten als Einflussfaktor 24 2.4.3 Bindungsmerkmale der Therapeuten als Einflussfaktor 26 2.4.4 Passung von Patient und Therapeut 27 2.5 Ziele der vorliegenden Arbeit 30 3 Fragestellungen und Hypothesen 33 4 Methoden 35 4.1 Studienbeschreibung 35 4.2 Ein- und Ausschlusskriterien 36 4.3 Studienablauf 40 4.4 Studiendesign der vorliegenden Arbeit 41 4.5 Ablauf der Therapie 42 4.6 Operationalisierung der Variablen 42 4.6.1 Diagnostik der Psychischen Störungen 44 4.6.2 Allgemeine psychische Symptomatik 45 4.6.3 Depressive Symptomatik 47 4.6.4 Angstspezifische Symptomatik 49 4.6.5 Bindung 51 4.6.5.1 Bindungsstil 51 4.6.5.2 Bindungsrepräsentation 55 4.7 Stichprobenbeschreibung 57 4.7.1 Gesamtstichproben der gesunden und erkrankten Probanden 58 4.7.2 Substichprobe der behandelten Patienten 62 4.7.3 Therapeuten 65 4.8 Analyse und Umgang mit fehlenden Werten 65 4.9 Statistisches Prozedere 68 4.9.1 Analyse der Bindungsunterschiede zwischen Patienten und Gesunden 68 4.9.2 Überprüfung der Therapiewirksamkeit 68 4.9.3 Vorüberlegungen zur Auswertung der dritten und vierten Fragestellung 69 4.9.4 Einfluss der Bindungsmerkmale der Patienten auf das Therapieergebnis 70 4.9.5 Einfluss der Patient-Therapeuten-Passung auf das Therapieergebnis 72 4.9.6 Signifikanz und Effektstärken 73 5 Ergebnisse 74 5.1 Bindungsunterschiede zwischen Patienten und Gesunden 74 5.2 Wirksamkeit der Therapie 77 5.3 Deskriptive Ergebnisse hinsichtlich der Bindung in der Therapie-Stichprobe 82 5.3.1 Patienten 82 5.3.2 Therapeuten 83 5.4 Einfluss der Bindungsmerkmale der Patienten auf das Therapieergebnis 84 5.4.1 Angstbezogene Kognitionen 84 5.4.2 Körperbezogene Ängste 85 5.4.3 Vermeidung 86 5.4.4 Allgemeine psychische Symptomatik 88 5.5 Einfluss der Patient-Therapeuten-Passung auf das Therapieergebnis 93 5.5.1 Angstbezogene Kognitionen 93 5.5.2 Körperbezogene Ängste 94 5.5.3 Vermeidung 94 5.5.4 Allgemeine psychische Symptomatik 95 6 Diskussion 97 6.1 Bindungsunterschiede zwischen Patienten und Gesunden 97 6.2 Wirksamkeit der Therapie 101 6.3 Einfluss der Bindungsmerkmale der Patienten auf das Therapieergebnis 103 6.4 Einfluss der Patient-Therapeuten-Passung auf das Therapieergebnis 108 6.5 Stärken und Limitierungen der Arbeit sowie Ausblick 112 6.6 Abschließende Bewertung 115 7 Zusammenfassung 116 8 Summary 119 9 Literaturverzeichnis 122 10 Anhang 140 10.1 Anhang A: Diagnostische Kriterien 141 10.2 Anhang B: Übersicht des Therapieablaufs in der Angst-Tagesklinik 144 10.3 Anhang C: Prüfung der Voraussetzungen 145 10.4 Anhang D: Weiterführende Berechnungen 149 11 Danksagung 156 12 Erklärungen zur Eröffnung des Promotionsverfahrens 158 13 Erklärung über die Einhaltung gesetzlicher Bestimmungen 159 / Background and Questions: Panic disorder and agoraphobia are among the most common anxiety disorders. Despite treatment according to guidelines, about one third of patients do not benefit from therapy or relapses occur. Therefore, it is all the more important to identify factors that might have an influence on the therapy and could predict therapy outcome. One of these factors might be derived from the findings based on the attachment theory developed by John Bowlby. In the present study we investigated the predictive influence of attachment patterns on therapy outcome in patients with panic disorder and/or agoraphobia (primary diagnosis). Results from previous studies suggest that patients with mental disorders have a less secure attachment than healthy control subjects. In addition, patients with a secure attachment showed a higher benefit from psychotherapy. However, there are also studies that did not find any correlation between attachment security and therapy outcome. Overall, the findings are ambiguous. Potential reasons for contradictory results regarding this matter could be that previous studies often mixed different disorders and varied in terms of type or setting of the therapy. Furthermore, different measures (self-assessment vs. third-party assessment) were used to assess attachment. It also remains questionable if the influence of attachment only shows in psychodynamic therapies. Since the gold standard in treating patients with panic disorder or agoraphobia is exposure-focused cognitive-behavioral therapy, it is all the more important to investigate the influence of attachment in this form of therapy. It has also been shown that the matching of patient and therapist plays an important role in therapy. However, there is only poor study evidence concerning the matching with regard to attachment. Up to now, only few studies have been conducted in an actual therapeutic context. There is a lack of studies focusing on the influence of attachment-related matching on symptom reduction. These methodological issues have been taken into account in this dissertation in order to answer the following questions: Do patients with a panic disorder and/or agoraphobia differ from healthy subjects of comparable age, gender and educational level with respect to their attachment style and/or attachment representation? How does guideline-adherent therapy affect the patients in the short and long term? Is there a correlation between the patients’ attachment style or attachment representation and therapy outcome at the end of therapy, 3 months or 1 year after end of therapy? How does attachment-related matching between patients and therapists influence therapy outcome? Methods: 175 patients with a panic disorder and/or agoraphobia (only primary diagnosis) and 143 healthy participants took part in the study. Using standardized diagnostics, subjects with personality disorders and various other mental disorders were excluded. Subsequently, 103 patients underwent standardized five-week treatment at the Day-Clinic for Anxiety Disorders of the Department of Psychotherapy and Psychosomatics at the University Hospital Dresden. The treating therapists also took part in the study. In all subjects, the attachment representation (external rating) was assessed with the Adult Attachment Interview (AAI). The attachment style (self-assessment) was measured with the Adult Attachment Scale and the Bielefeld Partnership Expectations Questionnaire, respectively the Bielefeld Client Expectations Questionnaire. Therapy outcome measures were the overall symptom distress, measured with the so-called Global Severity Index (GSI), and the severity of depression, each captured at therapy onset (t1), end of therapy (t2) and at a 3-month (t3) and 1-year follow-up (t4). In addition, anxiety-specific symptoms were assessed using various questionnaires on body-related anxieties, cognitions and agoraphobic avoidance behavior (alone and when accompanied). Results: In line with expectations, the patients showed a more insecure attachment than the healthy participants both in the self-assessment instruments and the AAI. The differences achieved small effect sizes in the categorical differentiation and small to medium effect sizes in the differentiation according to attachment scales. The patients primarily showed a disorganized, followed by an insecure-dismissing attachment representation in the AAI. In accordance with the hypothesis, the anxiety symptoms, the depressive and the overall symptom distress decreased towards end of therapy. Effect sizes ranged from medium to high. In addition, the effects remained stable in all therapy outcome measures and even improved in the time span between end of therapy and 1-year follow-up. Regarding the influence of the patients' attachment representation on therapy outcome, there were only some trends for the agoraphobic avoidance at the time of follow-up, mainly for the AAI scale dismissing-preoccupied. However, hypothesized correlations between an insecure attachment style (characterized by a low readiness for self-disclosure, high fear of rejection and a low need for care) and a higher GSI-score at t3 were found. Furthermore, higher fear of rejection and a lower need for care predicted a stronger agoraphobic avoidance alone at t3. Higher fear of rejection was also associated with greater avoidance when accompanied at t3 and t4. Only seven therapists, exhibiting a predominantly secure attachment in the AAI and the questionnaires, were included in the study. Hence, results for the attachment-related matching between patients and therapists are purely exploratory. For the AAI scale dismissing-preoccupied, significant correlations with the symptom domains body-related anxiety, avoidance and overall symptom distress were found. Standardized regression weights were very low, thus these results must still be interpreted only as trends. However, they might suggest that matching a more preoccupied patient with a more dismissing therapist is associated with a poorer therapy outcome. Also for the attachment style, only trends for body-related anxieties and the agoraphobic avoidance alone were found: dissimilarity between patient and therapist on the scale fear of rejection was associated with a poorer therapy outcome at t3 and t4. In addition, dissimilarity between patient and therapist with regard to the need for care scale was associated with higher avoidance alone at t3. Conclusion: Patients showed a more insecure attachment than healthy participants. The therapy had a beneficial effect on symptom severity and the patients’ attachment style had a low predictive influence on therapy outcome. In contrast, the patients’ attachment representation did not show a significant influence, and the exploratory analysis of the attachment-related matching between patient and therapists had very little predictive power regarding therapy outcome. Overall, the symptom severity at therapy onset played a major role in predicting the success of therapy for all symptom severity measures. The attachment characteristics seem to have an influence primarily on agoraphobic avoidance behavior at the time of follow-up. Higher fear of rejection and a more preoccupied attachment representation were associated with poorer therapy outcome. The question on whether attachment-related matching has an influence on therapy outcome remains elusive due to the small sample of therapists. Nevertheless, it is worthwhile to continue research in this regard and to replicate the present results on a larger sample. The small correlations found with regard to the AAI scale dismissing-preoccupied might indicate that matching may possibly only come into play if an insecurely attached patient is treated by an insecurely attached therapist. Future studies should therefore focus on a further differentiation between preoccupied and dismissing attachment.:Inhaltsverzeichnis I Abbildungsverzeichnis IV Tabellenverzeichnis V Abkürzungsverzeichnis VII 1 Einleitung 1 2 Theoretischer Hintergrund 4 2.1 Panikstörung und Agoraphobie 4 2.1.1 Leitsymptomatik 4 2.1.2 Epidemiologie und Verlauf 4 2.1.3 Ätiologie 6 2.1.4 Behandlung 10 2.2 Grundlagen der Bindungstheorie 12 2.2.1 Definition und Entwicklung von Bindung 12 2.2.2 Erfassung von Bindungsrepräsentationen und Bindungsstilen 13 2.3 Bindung und Angststörungen 18 2.4 Bindungsaspekte im Psychotherapieprozess 23 2.4.1 Therapeutische Beziehung als Bindungsbeziehung 23 2.4.2 Bindungsmerkmale der Patienten als Einflussfaktor 24 2.4.3 Bindungsmerkmale der Therapeuten als Einflussfaktor 26 2.4.4 Passung von Patient und Therapeut 27 2.5 Ziele der vorliegenden Arbeit 30 3 Fragestellungen und Hypothesen 33 4 Methoden 35 4.1 Studienbeschreibung 35 4.2 Ein- und Ausschlusskriterien 36 4.3 Studienablauf 40 4.4 Studiendesign der vorliegenden Arbeit 41 4.5 Ablauf der Therapie 42 4.6 Operationalisierung der Variablen 42 4.6.1 Diagnostik der Psychischen Störungen 44 4.6.2 Allgemeine psychische Symptomatik 45 4.6.3 Depressive Symptomatik 47 4.6.4 Angstspezifische Symptomatik 49 4.6.5 Bindung 51 4.6.5.1 Bindungsstil 51 4.6.5.2 Bindungsrepräsentation 55 4.7 Stichprobenbeschreibung 57 4.7.1 Gesamtstichproben der gesunden und erkrankten Probanden 58 4.7.2 Substichprobe der behandelten Patienten 62 4.7.3 Therapeuten 65 4.8 Analyse und Umgang mit fehlenden Werten 65 4.9 Statistisches Prozedere 68 4.9.1 Analyse der Bindungsunterschiede zwischen Patienten und Gesunden 68 4.9.2 Überprüfung der Therapiewirksamkeit 68 4.9.3 Vorüberlegungen zur Auswertung der dritten und vierten Fragestellung 69 4.9.4 Einfluss der Bindungsmerkmale der Patienten auf das Therapieergebnis 70 4.9.5 Einfluss der Patient-Therapeuten-Passung auf das Therapieergebnis 72 4.9.6 Signifikanz und Effektstärken 73 5 Ergebnisse 74 5.1 Bindungsunterschiede zwischen Patienten und Gesunden 74 5.2 Wirksamkeit der Therapie 77 5.3 Deskriptive Ergebnisse hinsichtlich der Bindung in der Therapie-Stichprobe 82 5.3.1 Patienten 82 5.3.2 Therapeuten 83 5.4 Einfluss der Bindungsmerkmale der Patienten auf das Therapieergebnis 84 5.4.1 Angstbezogene Kognitionen 84 5.4.2 Körperbezogene Ängste 85 5.4.3 Vermeidung 86 5.4.4 Allgemeine psychische Symptomatik 88 5.5 Einfluss der Patient-Therapeuten-Passung auf das Therapieergebnis 93 5.5.1 Angstbezogene Kognitionen 93 5.5.2 Körperbezogene Ängste 94 5.5.3 Vermeidung 94 5.5.4 Allgemeine psychische Symptomatik 95 6 Diskussion 97 6.1 Bindungsunterschiede zwischen Patienten und Gesunden 97 6.2 Wirksamkeit der Therapie 101 6.3 Einfluss der Bindungsmerkmale der Patienten auf das Therapieergebnis 103 6.4 Einfluss der Patient-Therapeuten-Passung auf das Therapieergebnis 108 6.5 Stärken und Limitierungen der Arbeit sowie Ausblick 112 6.6 Abschließende Bewertung 115 7 Zusammenfassung 116 8 Summary 119 9 Literaturverzeichnis 122 10 Anhang 140 10.1 Anhang A: Diagnostische Kriterien 141 10.2 Anhang B: Übersicht des Therapieablaufs in der Angst-Tagesklinik 144 10.3 Anhang C: Prüfung der Voraussetzungen 145 10.4 Anhang D: Weiterführende Berechnungen 149 11 Danksagung 156 12 Erklärungen zur Eröffnung des Promotionsverfahrens 158 13 Erklärung über die Einhaltung gesetzlicher Bestimmungen 159

According to attachment theory, the establishment of an attachment bond to a caregiver not only provides the infant with protection from danger, but also many other resources presumably beneficial to the child’s general psychological development. Although there is substantial empirical support for a link between attachment security and social functioning in childhood and adolescence, less is known about whether childhood attachment contributes to social functioning beyond adolescence. Similarly, attachment has been found predictive of broad aspects of a person’s functioning, but few attempts have been made to link attachment to the currently dominating perspective on personality, the Five Factor Model (FFM). Results in Study I partially supported our expectations, by showing prospective links from middle childhood security to various aspects of social functioning in young adulthood. Further, security contributed to developmental change in social functioning from middle childhood to young adulthood. In Study II, middle childhood security was found to predict some of the FFM personality traits (primarily extraversion and openness) concurrently and prospectively, partially supporting our expectations. The third aim of this thesis was to address whether attachment disorganization, which has usually been found predictive of maladaptive phenomena, may predict also other, non-pathological outcomes. In Study II, we found that higher levels of disorganization in young adulthood were concurrently associated with more openness and lower conscientiousness. Furthermore, in Study III disorganization was shown to be concurrently associated with more New Age spirituality and more absorption in adulthood. In addition, absorption was, in accordance with our expectations, found to statistically mediate the link between disorganization and New Age spirituality. Hence, these findings supported our assumption that disorganization might be expressed in other life domains besides specifically maladaptive ones. Taken together, we suggest that attachment spreads its influence to a broad set of life domains through its continuous influence on general psychological components such as cognitive representations and self-regulation abilities. However, the modest strength of our results indicates that attachment is only one among several factors involved in the development of social functioning, personality traits, and spirituality.

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There is evidence that functions related to attachment may play an important role in the etiology and maintenance of eating disorders, particularly anorexia and bulimia nervosa (Kuipers & Bekker, 2012; Tasca & Balfour, 2014). However, there is little research available on attachment functioning in those with binge-eating disorder (BED). This dissertation consists of three studies that examine the role of attachment states of mind and attachment dimensions in understanding BED and co-morbid overweight, and to examine mechanisms related to group treatment response for those with BED. The first study assessed attachment state of mind classifications (i.e., attachment categories) to understand better: 1) the psychopathology and maintenance of BED and co-morbid overweight, and 2) the treatment response of women with BED who receive Group Psychodynamic Interpersonal Psychotherapy (GPIP; Tasca, Mikail, & Hewitt, 2005). Overweight women with BED (subsequently referred to as women with BED), overweight women without BED, and normal weight women without BED completed the Adult Attachment Interview (AAI; Main, Goldwyn, & Hesse, 2002). Those with BED completed the AAI pre- and six months post- GPIP and those without BED completed the AAI at one-time point. Women with BED have significantly higher rates of insecure (preoccupied) and unresolved/disorganized attachment states of mind compared to normal weight women without BED. Women with BED had similar rates of insecure and unresolved/disorganized attachment states of mind as overweight women without BED. With respect to treatment completers, changes in attachment states of mind were not statistically significant. However, follow-up analyses indicated clinically meaningful changes which are discussed in the study. The second study used attachment dimensions of coherence of mind and reflective functioning (measured using the AAI) to add to our understanding of the psychopathology and maintenance of BED and co-morbid overweight. Higher Reflective Functioning scores differentiated normal weight women from both women with BED and overweight women without BED, and the latter two groups did not differ from each other. Coherence of Mind scores did not differentiate the groups. The third study used attachment dimensions of coherence of mind and reflective functioning to understand better group psychotherapy response for those with BED who received GPIP. Greater reflective functioning at pre-treatment was associated with a decline in binge eating frequency at 12 months post-treatment. Pre-treatment levels of coherence of mind was not related to group treatment outcomes. Reflective Functioning scores significantly improved from pre- to six months post-treatment. Further, more than 39% of participants demonstrated clinically reliable improvement and almost 32% experienced clinically reliable recovery with respect to reflective functioning. These results were moderated by pre-treatment self-reported attachment anxiety. That is, those with lower attachment anxiety showed significant improvement in reflective functioning, whereas those with higher attachment anxiety did not show this improvement. A third of participants experienced clinically significant improvement in coherence of mind, but this change was not statistically significant. Overall, attachment dimensions and attachment state of mind classification contribute to our understanding of the etiology and maintenance of BED and co-morbid overweight, as well as to our understanding of the group treatment response of those with BED. Addressing attachment insecurity and low reflective functioning in those with BED may improve treatment outcomes.

Lilja, A. & Topilina, G. “Att jobba manualstyrt kräver en god kompetens”. En intervjustudie om Intervju om anknytningsstil i Sverige. Examensarbete i socialt arbete 15 högskolepoäng. Malmö universitet: Fakulteten för hälsa och samhälle, institutionen för socialt arbete, 2019. Standardiserade bedömningsmetoder är en del av socialarbetares vardag. Enligt Socialstyrelsen ökar intresset för att använda standardiserade metoder och ett evidensbaserat arbetssätt inom socialt arbete i Sverige. Samtidigt finns bristfällig information om vilka metoder som anses vara evidensbaserade och vilka som inte är det. Denna studie fokuserar på Intervju om anknytningsstil (IAS) - en standardiserad bedömningsmetod som syftar till att kartlägga och mäta kvalitet på klientens nära relationer. IAS saknar enligt Socialstyrelsen evidens och utvärdering men används i barn- och familjehemsutredningar. Syftet med studien är att ur ett organisationsteoretiskt perspektiv undersöka hur socialarbetare använder IAS i det praktiska sociala arbetet med fokus på de yrkesverksammas uppfattning av metoden och metodens roll i arbetsprocessen. Studien syftar även till att undersöka vilken tilltro socialarbetare har till metoden och resultatet samt om metoden har någon påverkan på kontakten med klienten. För att uppfylla studiens syften har sju socialarbetare intervjuats som använder IAS i sitt arbete. Studiens resultat visar att trots metodens standardiserade utformning skiljer sig användandet både gällande syfte och utförande. Informanterna har skilda uppfattningar om vilka slutsatser som kan dras av IAS och hur metoden påverkar relationen till klienten. De flesta respondenter betvivlar att IAS är knuten till forskning och uttrycker att metoden inte är tillräckligt effektiv och tidsenlig. Samtidigt ser flera av informanterna tydliga fördelar med att använda IAS i sitt arbete. / Lilja, A. & Topilina, G. “You Need to Be Very Competent to Use the Standardised Methods”. An Interview Study of Adult Attachment Interview in Sweden. Degree project in Social Work. 15 högskolepoäng. Malmö University: Faculty of Health and Society, Department of Social Work, 2019. Standardized assessment methods are part of the everyday lives of social workers. According to Socialstyrelsen, the interest in using standardized methods and an evidence-based approach in social work in Sweden is increasing. At the same time there is insufficient information about which methods are considered to be evidence-based and which are not. This study focuses on Attachment Style Interview (ASI) - a standardized assessment method that aims to map out and measure the quality of the client's close relationships. According to Socialstyrelsen, ASI is lacking in both evidence and evaluation, yet is used in home assessments where children are concerned. The purpose of the study is to investigate, from an organizational theoretical perspective, how social workers use ASI in their practical work, focusing on the perception of professionals regarding the method and the role of the method within the work process itself. The study also aims to investigate what trust social workers have regarding the method and its results, and whether the method has any influence over/on the contact with the client. To fulfill the aims of the study seven social workers currently using ASI in their daily work have been interviewed. The results of the study show that, despite the standardized design of the method, the use differs both in terms of purpose and design. The informants have different opinions about what conclusions can be drawn from the ASI, and how the method affects the relationship with the client. Most respondents doubt that the ASI is linked to research, and state that the method is not sufficiently effective nor contemporary. Nevertheless, several of the informants agree on clear advantages in using ASI in their work.

This study examined the ability to “fake-good” on the Adult Attachment Interview (AAI). Each of the 21 participants was administered the AAI and MMPI-2 under both “control” (non-faked) and “experimental” (instructed to fake-good) conditions. The scores received on the L and K validity scales of the MMPI-2 under the control versus the experimental conditions were compared to determine if the instructions that were intended to induce faking good in the experimental condition were successful. Significant differences were found between the experimental and control group on the MMPI-2 L and K scales suggesting that the instructions did induce faking good in the experimental condition. Once established, the scores received on the AAI idealization and coherence of mind scales during the control versus experimental condition were compared to determine if the experimental condition instructional set impacted (1) idealization positively, (2) coherence of mind negatively, and (3) overall attachment classification becoming more dismissing, as hypothesized. Significant differences were found between the experimental and control group on the AAI idealization scale and on the AAI coherence of mind scale. These results suggest that the individuals' idealization scores were significantly lower in the control versus experimental conditions while the individuals' overall coherence of mind scores were significantly higher in the control versus experimental conditions. Of the 12 who were found to be dismissing under the experimental condition, 4 had previously not been classified as dismissing when the standard AAI instructions were given. Even though the results were not indicative of a difference in attachment classification under the control versus experimental conditions, a trend was apparent. It appears that one attempting to fake good may appear more dismissing on the AAI than he/she really is. It is even more critical that this study be replicated using a larger sample size to determine if trying to make oneself look positively will impact overall attachment status.

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<p>The aim of the thesis was to examine the applicability of attachment theory to adult and adolescent religiosity. Attachment theory is an empirically oriented research paradigm that takes evolutionary theory as the starting point in the study of child-parent relations and their socioemotional correlates in development. The work consisted of two interrelated tasks. First, limitations in theory and research in the psychology of religion, particularly the traditional psychodynamic perspectives, were highlighted, and attachment theory was proposed as an integrative framework to remedy some of those limitations. Second, four empirical studies (I-IV), based on attachment theoretical predictions, were conducted to investigate relations between individual differences in attachment and religiosity. </p><p>The combined results from the studies suggest the existence of two religiosity profiles in relation to attachment. Both profiles resemble influential descriptions of individual religiosity differences in the psychology of religion literature. The religiosity of individuals in the first profile is similar to their parents' religiosity and is likely to be stable over time. If religious changes have been experienced, these are likely to be gradual, to occur early in life, and in a context pointing to the importance of relationships with religious significant others. Such individuals' God image is likely to be loving, and not distant. It was hypothesized that these religiosity characteristics stern from experiences with sensitive attachment figures in childhood, and that such experiences have promoted partial adoption of the attachment figures' religious standards. The mental representations of attachment resulting from the favorable experiences were suggested to be responsible for a corresponding image of a loving God. </p><p>The religiosity of individuals in the second profile is independent of parental religiosity, and is likely to fluctuate (increase and decrease) over time. Their religious changes are more sudden and intense, occur relatively later in life, and in a context pointing to an emotionally supportive function for religion. Such individuals' God image is more distant, and less loving. These religiosity characteristics were hypothesized to stem from experiences with insensitive attachment figures in childhood. It was suggested that they reflect an affect regulation strategy to obtain/maintain a sense of felt security, and that God is utilized as a compensatory attachment-like figure in this regard. </p><p>Findings pertaining to the profiles generally emerged regardless of whether the design was cross-sectional (I-IV) or longitudinal (III); whether participants were adults (I, II, and IV) or adolescents (Study III); and whether attachment was assessed with self-report questionnaires (I-IV) or independent ratings based on a semi-structured interview (IV).</p>