Starting from the ‘Strange Situation’ Procedure, developed by Ainsworth et al. in the 1970s to observe the relationship of attachment between mother and child, the attachment acquires a very important place in the study of the psychology of the toddler, but not only; it is currently one of the most important frameworks for understanding affect regulation and human relations .
Attachment offers the opportunity to develop social intelligence, or the ability to perceive / understand oneself and others in mental terms, defined as mentalization . This capacity ‘the mental process by which an individual implicitly and explicitly interprets the actions of oneself and others as meaningful on the basis of intentional mental states such as personal desires, needs, feelings, beliefs and reasons’ is deemed crucial for the development of the child into an autonomous adult who can socially function. Mentalization develops into a secure attachment relationship and in turn strengthens the attachment bond . With regard to eating disorders, prominent models tend to focus on cognitive and behavioral characteristics, disregarding aspects related to affect regulation, interpersonal style, self-concept and mentalization, aspects that are conceptualized within the attachment theory . By virtue of the above, this paper proposes the following:
– To prove the importance of attachment in the determinism of eating disorders, more specifically in the case of Anorexia Nervosa;
– To highlight the neurobiological basis of attachment disorders in Anorexia Nervosa;
– To highlight the trans-generational aspect of attachment and the importance of this aspect in working with the families of anorexic patients; To prove the importance of attachment in the therapeutic work of Anorexia Nervosa and implicitly its influence in the evolution of the disease. MATERIAL AND METHODS We have carried out, in order to achieve the above objectives, a review of the online literature available on sites such as PubMed, Medscape, etc., but also of several books and a thesis on the subject of attachment, respectively of eating disorders: Bowlby J., A Secure Base: Clinical Applications of Attachment Theory; Marinov V. – Anorexia a Strange Violence; Chatoor I.- Diagnosis and treatment of eating disorders in infants toddlers and young children; Kuipers GSAttachment and Mentalization in Anorexia Nervosa and Bulimia Nervosa.
1. CHILD ATTACHMENT: CONCEPT, CLASSIFICATION, ASSESSMENT INSTRUMENTS
Attachment is a fundamental form of behavior having its own internal motivation, distinctive from that of nurturing or sexual motivation, and being equally important for survival . The biological function assigned to it is that of protection. It is developed during the first months of life and has the effect of keeping the child more or less close to the maternal figure, thus increasing the chances of survival during the vulnerable period of childhood . From a psychological point of view, this behavioral system provides a secure affective basis necessary for the overall development of the individual .
Attachment behavior is any form of behavior that causes a person to reach, or stay close to another individual identified as being more capable of adapting to the environment . While attachment behavior may differ depending on the circumstances from one individual to another, however, a stable attachment, or attachment bond, concerns only few people . If a child does not have such a clear differentiation, he or she is likely to have a serious disorder . Starting from the ‘Strange Situation’ experiment, 3 main patterns of child attachment were identified, first presented by Ainsworth et al. in 1971:
– Secure Attachment: The individual trusts his or her parent (or parental figure) to be available, responsive and help if faced with adverse or frightening situations. Given this guarantee, he or she bravely explores the environment. This pattern of attachment is supported by a parent who is immediately available, perceives the child’s signals and/or responds with affection when he/she seeks protection and/or relief;
– Anxious-Ambivalent Attachment: In this case the individual does not have the certainty that the parent will be available or responsive, or that will help if requested. Due to this uncertainty, the individual is constantly prone to separation anxiety, tends to become anxious and expresses anxiety about exploring the environment. This pattern is supported by a parent who is sometimes available and helps, but sometimes not; It is also supported by repeated separations and threats of abandonment used as a means of control;
– Anxious-Avoidant Attachment: In this case the individual does not trust that if he/she seeks protection he/she will be answered and helped, on the contrary he/she expects to be categorically refused. If an individual presents this type of attachment to a high degree, he/she tries to live his/her life without the love and support of others .
Reactions of disorientation and / or disorganization of children were also observed in the study ‘Strange Situation’ , which were later interpreted as a disorganized / disoriented variant of attachment, and which was later added to the classification by Main and Solomon (1990)  The stability of the pattern, when observed, cannot be attributed to the innate temperament of the child, as has sometimes been said. However, as the child grows, the pattern gradually becomes a characteristic of the child himself/herself, this means that he/she tends to impose it upon new relationships .
The ‘Strange Situation’ procedure assesses attachment for children aged between 1 and 4 years old. Preschool Attachment Assessment is a change in PSS for children who have the ability to speak, walk and open doors .
For children aged 5-7 years old, the Manchester Narrative Assessment of Child Attachment can be used- which involves 4 different puppet scenarios, containing attachment topics, the narrative of which is continued freely by the child .
For children between 7 and 15 years old, either semi-structured interviews- such as the Child Attachment Interview, or projective methods- such as the School-age Assessment of Attachment, are used .
2. ADULT ATTACHMENT: CONCEPT, CLASSIFICATION, ASSESSMENT INSTRUMENTS
Adult attachment occurs as a result of the entire attachment history. Thus, from this perspective, attachment traits can be changed by later life events and experiences with various other significants . Attachment classification for adolescents and adults refers to mental representations, or so-called Internal working models of attachment, while attachment classification for children refers to the current parent-child relationship . Moreover, unlike the classification of child attachment, which is strictly categorical, in adults the attachment system was developed conceptually, around two dimensions / axes: Avoidance and anxiety. Avoidance reflects the degree to which the individual feels comfortable with closeness and emotional intimacy in relationships .
Avoidant people strive to create and maintain independence, control and autonomy in their relationships because they believe that seeking psychological / emotional proximity to romantic partners is either not possible or undesirable . These beliefs motivate avoidant people to employ distancing / deactivating coping strategies to promote independence / autonomy . The second dimension – anxiety – assesses the degree to which the individual worries about being underappreciated or abandoned by their romantic partners . Highly anxious individuals are heavily investing in their relationships, and they yearn to get closer to their romantic partners to feel more secure. Anxious individuals harbor a low self-esteem and are concerned about the loss of their romantic partners, remaining vigilant to signs of their partners pulling away from them. Accordingly, these individuals tend to use emotion-focused / hyper-activating coping strategies when distressed, which sustain or even escalate these concerns and keep the attachment system chronically activated .
AAI – Adult Attachment Interview and AAP – Adult Attachment Projective Picture System are 2 narrative interviews that can be used in assessing attachment of adolescents over 15 years old and adults . AAI designates 5 attachment patterns – secure, dismissing, preoccupied, unresolved, and cannot-classify .
The PAA identifies the 4 standard types of adult attachment patterns – safe, dismissing, preoccupied, and a disorganized onecalled unresolved . Within AAI, subjects are asked to describe current and childhood experiences related to their caregivers and to recall events specifically related to attachment . Individuals with secure attachment are able to reflect and integrate negative experiences with their caregivers and their assessment of attachment experiences is coherent . In contrast, insecure-dismissing individuals tend to idealize or devaluate their attachment experiences by deactivation of attachment distress .
Insecurepreoccupied individuals are enmeshed with their caregivers and they show anger and low autonomy in their narrative evaluation . Finally, those with unresolved attachment category show a breakdown of defensive and coping strategies in their speech about traumatic experiences such as loss or abuse . AAP is a measurement of affect based on the analysis of narrative responses to a set of drawings, related to attachment, or scenes that suggest solitude, illness, separation, death, and potential abuse . Secure attachment individuals demonstrate the ability to think about attachment related distress, and also describe mutual enjoyment in their relationships to others . Those with insecuredismissing attachment are characterized by the predominance of deactivating defensive processes that emphasize distance in relationships . The speech of insecure-preoccupied individuals includes material that obstructs and confuses attachment relationships; They unclearly reproduce various personal experiences . Unresolved attachment individuals are not able to contain and reorganize narratives that include danger, helplessness, isolation, failed protection . They become overwhelmed with attachment fears that cannot be reorganized into narration .
ATTACHMENT IN ANOREXIA NERVOSA
Although attachment disorders are not specific to eating behavior disorders, occurring in various psychopathologies , attachment insecurity is a well-established risk factor for these pathologies in general, and more specifically for anorexia , the prevalence of insecure attachment in eating disorders is estimated between 70 and 100%; Moreover, the severity of symptoms may be correlated with the degree of insecure attachment . Regarding the attachment of children with Infantile Anorexia Nervosa (according to the diagnostic criteria DR:0-3R), these toddlers exhibit a higher rate of insecure attachment relationships than healthy eaters, although the majority of anorexic children (60%) have shown secure attachment patterns . However, the significant correlation between the severity of malnutrition and the degree of attachment insecurity indicates that an insecure toddler-mother relationship is associated with a more severe expression of Infantile Anorexia. Furthermore, Infantile Anorexia Nervosa occurs during the separation and individuation period, when children are involved in intense struggles with their mothers for autonomy and control, especially during feeding, but sometimes also during play; Due to the vicious circle that is created between the child who seems to have a poor hunger drive, is too distracted, overexcited, to feed and the mother who distracts the child’s attention through various methods to be able to feed him/her, the child does not learn to regulate eating internally, which becomes completely dependent on the child’s interactions with the caregiver . The patterns of interaction between mother and child, characterized by less dyadic reciprocity, high dyadic conflict, struggle for control and distractions during feedings , maintain the vicious circle and, therefore, the pathology. Attachment dysfunction, along with a poor parentchild connection, may contribute to poor reflexive abilities, difficulties in emotional adjustment, even a lower ability to recognize hunger and satiety . The ‘psychic equivalent’ mode of experiencing reality implies that psychic inner states are not experienced distinctly by the sensory-motor experiences, or bodily sensations, such as hunger . Alexithymia, another concept often highlighted in patients with Anorexia Nervosa, which refers to difficulties in identifying, labeling, describing, processing and regulating bodily sensations, emotions and affections, causes major frustrations in interpersonal conflicts, issues that lead to maladaptive emotional adjustment strategies, including the actual symptoms of the disease . Regarding the specific type of attachment found in Anorexia Nervosa, studies show different results, which can be explained by associated comorbidities, e.g. personality . In restricting type anorexia, compulsive, perfectionistic personality traits and avoidant personality disorder can be observed, while purgative anorexia can result from high impulsivity and borderline organization . Some studies describe rather an anxious attachment in anorexic patients, with a varying degree of ambivalence or avoidance , others highlight a high incidence of unresolved attachment . Interestingly, the predominance of unresolved attachment was also found in the mothers of patients . Unresolved attachment (trauma or unresolved abuse) is designed as an analogue to the child’s disorganized attachment pattern . This pattern can develop not only via traumas such as separation due to adoption, premature birth, or physical trauma, but also through subtle and traumatic experiences of lack of maternal adjustment . In individuals with unresolved attachment, there are multiple segregated internal attachment patterns that are kept completely out of awareness, patterns created as extreme forms of defense in response to severe conditions perceived as threats to attachment . This causes the individual to maintain a facade while avoiding the discomfort associated with the conflict . The cost of such a form of defense is the risk of reviving, but also disturbances in thinking and behavior in situations of attachment activation . Regarding the perception of patients of their own parents, some studies show a negative perception of parental care, as it does not offer sufficient emotional support in relation to their personal needs and is not oriented towards stimulating autonomy . Other studies show, paradoxically, an idealization of parents, mothers being perceived as very good facilitators of independence . Although the paternal role has not been investigated that much, it seems that both negligence and overprotection are associated with a higher risk of mood disorders, bodily dissatisfaction, healthier eating habits, including restrictive eating, than in the case of paternal benefactor attachment . In relation to the paternal figure, for the cases of Anorexia Nervosa encountered in therapy, V. Marinov finds a father who is deficient, either by a presence sometimes felt as excessive, because, in the first stage of the child’s life, the father was more physically and mentally present than the mother, either because the father is away, absent, weak, and the mother dominant, omnipresent . In all cases, the father is deficient . Marinov also points out that one of the characteristics of parental gaze is it being placed rather in the self-preservation register rather than in the affective register, ensuring body care, concern for the health of the child, for his/ her intellectual performances . „I took care he/she has everything he/she needs” (from a material point of view) .
TRANSGENERATIONAL ASPECTS IN ATTACHMENT
Clinicians and researchers have associated mothers’ difficulty in engaging with their children, with their own deprivation in the past, but also with their present relational difficulties . Mary Main has found a high degree of correlation between how the mother describes the relationship that she had in her childhood with her parents and the attachment pattern that the child shows in the relationship with her . Ward et al (2001) highlight a transgenerational transmission of attachment; Many anorexic mothers reveal unresolved loss, trauma and attachment style just like their daughters . Given that parenting style is often passed down from generation to generation, the study by Chatoor and colleagues (2000) reviewed mothers’ attachment to their parents, the authors showing that more mothers in the group of children with Infantile Anorexia showed patterns of insecure attachment to their parents, compared to mothers in the group with picky eating style, or to the control group. In addition, insecure attachment to the mother was associated with the intensity of conflict between mother and child during feeding . However, it should be noted that not all mothers of anorexic children show insecure attachment . Unresolved trauma in the case of the mother may lead to impaired responsiveness to his/her child and thus may contribute to the trans-generational transmission of the trauma . In most cases, dealing with the problems of bereavement occurs; bereavement of patients or, more frequently, of the parents of anorexic patients . The mother or father suffered the loss of one of the parents shortly before the birth of the daughter, the parents lost a child in utero, or still young before the birth of the daughter, the couple was expecting the birth of another child, the 2 branches of the family are perceived as incompatible, an incestual or incestuous relationship with the father attenuates a relationship with a cold and depressed mother . In these situations, the child who is ‘badly received’, whom Ferenczi speaks about, tends to express a diminished aggression towards the external object and develops much easier a sub-investment of his/her vital functions .
THE NEUROIMAGING GROUNDING OF ATTACHMENT
Modern neuroimaging, together with attachment theory, have been applied together to bring new insights into the pathogenesis of eating disorders . Recent studies in anorexia reveal a significant reduction of white matter, per global, focal and volume reduction of gray matter in: the cerebellum, hypothalamus, caudate nucleus and frontal, parietal and temporal areas, as well as an enlargement of the ventricles . Atrophic areas in Anorexia Nervosa may be hypofunctional prior to the onset of the disease due to the impairment of attachment functions and of anger management inherent in this disease . The onset of eating disorders in adolescence, when brain maturation is incomplete, implies a high vulnerability for long-term and short-term alterations due to malnutrition . Certain brain areas such as the thalamus, midbrain, paracentral lobe, the hippocampus- amygdala complex, and anterior cingulate cortex are particularly affected by the effects of malnutrition in Anorexia Nervosa . Few studies have investigated the neurological correlates of attachment using Functional Magnetic Resonance . Some indicate a possible network of cortical and subcortical areas, involved in the attachment system including the amygdala, thalamus and frontal cortex . During the administration of the Adult Attachment Scale, in some studies it has been shown that participants with unresolved attachment exhibit an increased activation in the amygdala and hippocampus , which are fundamental components of the limbic system. Also, correlations between the activity levels within the amygdala and attachment insecurity have been observed in some studies . In a study by Cicereale et al., various subscales of the attachment scale correlate with the volume of gray matter in different areas of the brain . Higher passivity was correlated with lower volumes of gray matter in the mesial areas, such as precuneus, which are correlated with autobiographical memory and self-referential processes . Due to the eminently structural correlations of the attachment, parenting influences may produce specific alterations on brain trophism that may represent the original wound from which eating psychopathology develops . The experience of love seems to play a protective role with positive effects on brain trophism while anger plays a role in producing atrophy in the gray matter of different areas . Maternal love is positively correlated with a network of neural circuits that overlap to those related to the Coherence of Mind and Coherence of the Transcript (considered in the AAI coding system as the most accurate indicator of the state of mind with respect to attachment), w hile anger was negatively correlated with parts of the same network . These alterations of the neural circuits may suggest that therapy may also target direct stimulation of brain dysfunctional areas by applying techniques such as Specific Transcranial Magnetic Stimulation, or Deep Brain Stimulation . THE IMPORTANCE OF
ATTACHMENT IN THE THERAPEUTIC FRAMEWORK OF ANOREXIA
Although attachment security and mentalization are not always directly and specifically correlated with the severity of eating behavior symptoms, a higher level of mentalization seems to accelerate the positive effect of psychotherapeutic treatment of the eating disorder as well as of the comorbid symptoms . Education about proper nutrition may be of lesser relevance for brain development than the promotion of the emotional and affective nurture of a loving parenting . Reactivation of attachment circuits can be achieved through corrective emotional experiences such as individual psychotherapy, family therapy or other family approaches (such as counseling) . This reactivation in a secure environment, with the possibility of correction, can lead to the improvement of the attachment security which, although not related to the reduction of the feeding disorder itself, might contribute to patients’ interpersonal functioning and quality of life . The current joints between the attachment and the neural circuits mentioned above suggest the need for reflection on the possible preventive interventions on eating disorders . At the same time, these alterations of the neural circuits suggest that therapy may also target direct stimulation of brain dysfunctional areas by applying techniques such as Specific Transcranial Magnetic Stimulation, or Deep Brain Stimulation .
Eating disorders are complex psychiatric disorders, representing an intersection between the suffering of the mind and the suffering of the body, and can be considered the prototype of psychosomatic diseases . The current paradigma in the study of eating disorders consider, in addition to the cognitivebehavioral characteristics, aspects related to affective regulation, the concept of self and mentalization, aspects closely related to attachment. Although attachment disorders are not specific to eating disorders, attachment insecurity is a wellestablished risk factor for these pathologies, implicitly for Anorexia Nervosa.
Attachment dysfunctionality may contribute to poor reflexive abilities, difficulties in emotional regulation, or even a poorer ability to recognize hunger and satiety, well-known risk factors for the development of eating disorders. Regarding the specific type of attachment found in Anorexia Nervosa, studies show different results, which can be explained by associated comorbidities, e.g. personality. High incidences have been demonstrated both for anxious attachment (with varying degree of ambivalence or avoidance) and for the unresolved attachment. Studies also show a trans-generational transmission of attachment, with a high degree of correlation between how the mother describes the relationship she had in her childhood with her parents and the attachment pattern that the child presents in the relationship with her.
The function of attachment is biologically grounded in neurobiological substrates, Functional Magnetic Resonance indicating a possible network of cortical and sub-cortical areas, involved in the attachment system , correlations between the attachment type and the activity in different such areas, or between different subscales of the attachment and the gray matter volume in these areas being proven in different studies.
These aspects suggest that the therapy could target both the reactivation-correction of attachment connections as well as a possible direct stimulation of the dysfunctional areas of the brain by various techniques, contributing alongside the already established therapeutic methods to a holistic approach to the pathology, to the improvement of interpersonal relationships and to an increased quality of life.
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