Using the attachment network Q-sort for profiling one's attachment style with different attachment-figures.

Attachment instruments vary substantially in practicability of administration, employment of categorical versus dimensional scoring, quality of scales, and applicability to different attachment figures. The Attachment Network Q-sort (ANQ) is a self-report, quasi-qualitative instrument that discriminates relationship-specific attachment styles for multiple attachment figures. The current study assesses the properties of the ANQ in psychotherapy patients and in non-patient respondents, using mother, father and romantic partner as possible attachment figures. Analyzing the ANQ-data with latent class analysis, we found four types or classes of participants: a group with an overall secure profile, a group only insecure for father, a group only insecure for mother, and a group insecure for mother as well as father but not for partner (if available). These profiles proved to have good concurrent, discriminant and construct validity. We conclude that the ANQ is potentially a useful alternative clinical self-report instrument to assess combinations of attachment styles for a range of attachment figures such as parents and a romantic partner.

The 5-HTTLPR genotype, early life adversity and cortisol responsivity to psychosocial stress in women.

BACKGROUND: The serotonin transporter gene-linked polymorphic region (5-HTTLPR) has previously been associated with hypothalamus-pituitary-adrenal axis function. Moreover, it has been suggested that this association is moderated by an interaction with stressful life experiences. AIMS: To investigate the moderation of cortisol response to psychosocial stress by 5-HTTLPR genotype, either directly or through an interaction with early life stress. METHOD: A total of 151 women, 85 of which had personality psychopathology, performed the Trier Social Stress Test while cortisol responsivity was assessed. RESULTS: The results demonstrate a main effect of genotype on cortisol responsivity. Women carrying two copies of the long version of 5-HTTLPR exhibited stronger cortisol responses to psychosocial stress than women with at least one copy of the short allele (P = 0.03). However, the proportion of the variance of stress-induced cortisol responsivity explained by 5-HTTLPR genotype was not further strengthened by including early life adversity as a moderating factor (P = 0.52). CONCLUSIONS: Our results highlight the need to clarify gender-specific biological factors influencing the serotonergic system. Furthermore, our results suggest that childhood maltreatment, specifically during the first 15 years of life, is unlikely to exert a moderating influence of large effect on the relationship between the 5-HTTLPR genotype and cortisol responsivity to psychosocial stress. DECLARATION OF INTEREST: None.

The levonorgestrel-releasing intrauterine device potentiates stress reactivity.

BACKGROUND: The levonorgestrel-releasing intrauterine device (LNG-IUD) is currently recommended as a first-line contraceptive with an exclusively local intrauterine influence. However, recent clinical trials have identified side effects of LNG-IUD that appear to be systemically mediated, including depressed mood and emotional lability. METHODS: We performed two experimental studies and a cross-sectional study. For each study, women were included from three groups: LNG-IUD (0.02mg/24h), oral ethinylestradiol/levonorgestrel (0.03mg/0.15mg; EE30/LNG) and natural cycling (NC). Study 1-Salivary cortisol was measured at baseline and at defined intervals following the Trier Social Stress Test (TSST). Heart rate was monitored continuously throughout the TSST. Study 2-Salivary cortisol and serum total cortisol were evaluated relative to low-dose (1µg) adrenocorticotropic hormone (ACTH) administration. Study 3-Hair cortisol was measured as a naturalistic index of long-term cortisol exposure. RESULTS: Women using LNG-IUD had an exaggerated salivary cortisol response to the TSST (24.95±13.45 nmol/L, 95% CI 17.49-32.40), compared to EE30/LNG (3.27±2.83 nmol/L, 95% CI 1.71-4.84) and NC (10.85±11.03nmol/L, 95% CI 6.30-15.40) (P<0.0001). Heart rate was significantly potentiated during the TSST in women using LNG-IUD (P=0.047). In response to ACTH challenge, women using LNG-IUD and EE30/LNG had a blunted salivary cortisol response, compared to NC (P<0.0001). Women using LNG-IUD had significantly elevated levels of hair cortisol compared to EE30/LNG or NC (P<0.0001). CONCLUSIONS: Our findings suggest that LNG-IUD contraception induces a centrally-mediated sensitization of both autonomic and hypothalamic-pituitary-adrenal (HPA) axis responsivity. LNG-IUD sensitization of HPA axis responsivity was observed acutely under standardized laboratory conditions, as well as chronically under naturalistic conditions.

Borderline and cluster C personality disorders manifest distinct physiological responses to psychosocial stress.

BACKGROUND: Maladaptive emotional control is a defining feature of personality disorders. Yet little is known about the underlying physiological dynamics of emotional reactivity to psychosocial stress across distinct personality disorders. The current study compared subjective emotional responses with autonomic nervous system and HPA axis physiological responses to psychosocial stress in women with cluster C personality disorder (CPD) and borderline personality disorder (BPD). METHODS: Subjective mood ratings, salivary cortisol, heart rate (HR), and skin conductance level (SCL) were assessed before, during, and after exposure to a standardized psychosocial stress paradigm (Trier Social Stress Test, TSST) in 26 women with BPD, 20 women with CPD, and 35 healthy female controls. Subjects were free of any medication including hormonal contraceptives, had a regular menstrual cycle, and were tested during the luteal phase of their menstrual cycle. RESULTS: Both CPD and BPD patients reported a similar burden of subjective mood disturbance. However, only BPD patients demonstrated reduced baseline cortisol levels with a blunted cortisol and HR reactivity to the TSST. In addition, BPD patients exhibited a generalized increase of SCL. No significant differences in baseline or TSST reactivity of cortisol, HR, or SCL were observed between CPD patients and healthy controls. CONCLUSION: These findings indicate that patients with BPD have significant alterations in their physiological stress reactivity, which is notably distinct from patients with CPD and those of healthy controls.

Patients with unexplained physical symptoms have poorer quality of life and higher costs than other patient groups: a cross-sectional study on burden.

BACKGROUND: To determine whether healthcare resources are allocated fairly, it is helpful to have information on the quality of life (QoL) of patients with Unexplained Physical Symptoms (UPS) and on the costs associated with them, and on how these relate to corresponding data in other patient groups. As studies to date have been limited to specific patient populations with UPS, the objective of this study was to assess QoL and costs in a general sample of patients with UPS using generic measures. METHODS: In a cross-sectional study, 162 patients with UPS reported on their QoL, use of healthcare resources and lost productivity in paid and unpaid work. To assess QoL, the generic SF-36 questionnaire was used, from which multidimensional quality-of-life scores and a one-dimensional score (utility) using the SF-6D scorings algorithm were derived. To assess costs, the TiC-P questionnaire was used. RESULTS: Patients with UPS reported a poor QoL. Their QoL was mostly decreased by limitations in functioning due to physical health, and the least by limitations in functioning due to emotional problems. The median of utilities was 0.57, and the mean was 0.58 (SD = .09).The cost for the use of healthcare services was estimated to be €3,123 (SD = €2,952) per patient per year. This cost was enlarged by work-related costs: absence from work (absenteeism), lower on-the-job productivity (presenteeism), and paid substitution of domestic tasks. The resulting mean total cost was estimated to be €6,815 per patient per year. CONCLUSIONS: These findings suggest that patients with UPS have a high burden of disease and use a considerable amount of healthcare resources. In comparison with other patient groups, the QoL values of patients with UPS were among the poorest and their costs were among the highest of all patient groups. The burden for both patients and society helps to justify the allocation of sufficient resources to effective treatment for patients with UPS.

Psychometrics and validity of the Dutch Experiences in Close Relationships-Revised (ECR-r) in an outpatient mental health sample.

The Experiences in Close Relationships-Revised (ECR-r) is a self-report instrument to assess adult attachment style that seems to have appropriate psychometric qualities. The ECR-r has been most widely studied in student and community samples. In this study we report factor structure, reliability, and construct validity of the Dutch translation of the ECR-r in an outpatient mental health sample (N = 262). The original factor structure could satisfactorily be replicated, the reliability of the ECR-r was also stable over time, and there was good evidence for its construct validity.

Predicting the outcome of a cognitive-behavioral group training for patients with unexplained physical symptoms: a one-year follow-up study.

BACKGROUND: Although Cognitive-Behavioral Therapy (CBT) is effective for Unexplained Physical Symptoms (UPS), some therapists in clinical practice seem to believe that CBT outcome will diminish if psychiatric comorbidity is present. The result is that patients with a psychiatric comorbidity are redirected from treatment for UPS into treatment for mental health problems. To explore whether this selection and allocation are appropriate, we explored whether CBT outcomes in UPS could be predicted by variables assessed at baseline and used in routine-practice assessments. METHODS: Patients (n=162) with UPS classified as undifferentiated somatoform disorder or chronic pain disorder were followed up until one year after they had attended a CBT group training. The time-points of the follow-up were at the end of CBT (immediate outcome), three months after CBT (short-term outcome), and one year after CBT (long-term outcome).CBT outcome was measured using the Physical Component Summary of the SF-36, which was the primary outcome measure in the randomized controlled trial that studied effectiveness of the CBT group training. Predictors were: 1.) psychological symptoms (global severity score of SCL-90), 2.) personality-disorder characteristics (sum of DSM-IV axis II criteria confirmed), 3.) psychiatric history (past presence of DSM-IV axis I disorders), and 4.) health-related quality of life in the mental domain (mental component summary of SF-36). The effect of this predictor set was explored using hierarchical multiple regression analyses into which these predictors had been entered simultaneously, after control for: a.) pretreatment primary outcome scores, b.) age, c.) gender, d.) marital status, and e.) employment. RESULTS: The predictor set was significant only for short-term CBT outcome, where it explained 15% of the variance. A better outcome was predicted by more psychological symptoms, fewer personality-disorder characteristics, the presence of a psychiatric history, and a better quality of life in the mental domain. CONCLUSIONS: As the predictors do not seem to predict CBT outcome consistently over time, the need for selection and allocation of patients for CBT is doubtful. It seems that this would unnecessarily deprive patients of effective treatment. TRIAL REGISTRATION: Nederlands Trial Register, NTR1609.

Effective group training for patients with unexplained physical symptoms: a randomized controlled trial with a non-randomized one-year follow-up.

BACKGROUND: Although cognitive-behavioral therapy for Unexplained Physical Symptoms (UPS) is effective in secondary care, studies done in primary care produced implementation problems and conflicting results. We evaluated the effectiveness of a cognitive-behavioral group training tailored to primary care patients and provided by a secondary community mental-health service reaching out into primary care. METHODOLOGY/PRINCIPAL FINDINGS: The effectiveness of this training was explored in a randomized controlled trial. In this trial, 162 patients with UPS classified as undifferentiated somatoform disorder or as chronic pain disorder were randomized either to the training or a waiting list. Both lasted 13 weeks. The preservation of the training's effect was analyzed in non-randomized follow-ups, for which the waiting group started the training after the waiting period. All patients attended the training were followed-up after three months and again after one year. The primary outcomes were the physical and the mental summary scales of the SF-36. Secondary outcomes were the other SF-36-scales and the SCL-90-R. The courses of the training's effects in the randomized controlled trial and the follow-ups were analyzed with linear mixed modeling. In the randomized controlled trial, the training had a significantly positive effect on the quality of life in the physical domain (Cohen's d = 0.38;p = .002), but this overall effect was not found in the mental domain. Regarding the secondary outcomes, the training resulted in reporting an improved physical (Cohen's d = 0.43;p = 0.01), emotional (Cohen's d = 0.44;p = 0.01), and social (Cohen's d = 0.36;p = 0.01) functioning, less pain and better functioning despite pain (Cohen's d = 0.51;p = <0.001), less physical symptoms (Cohen's d = -.23;p = 0.05) and less sleep difficulties (Cohen's d = -0.25;p = 0.04) than time in the waiting group. During the non-randomized follow-ups, there were no relapses. CONCLUSIONS/SIGNIFICANCE: The cognitive-behavioral group training tailored for UPS in primary care and provided by an outreaching secondary mental-health service appears to be effective and to broaden the accessibility of treatment for UPS. TRIAL REGISTRATION: TrialRegister.nl NTR1609

Alexithymia does not predict the persistence of medically unexplained physical symptoms.

BACKGROUND: Alexithymia is thought to be associated with the development of medically unexplained physical symptoms (UPS). So far little research has been published on alexithymia as a risk factor for the persistence of UPS. OBJECTIVE: To determine the clinical outcome in UPS patients and to study the relative importance of alexithymia in predicting that outcome. METHODS: A follow-up study was conducted among general medical outpatients with UPS. Patients underwent extensive examinations at baseline and were reassessed after a mean 61-week interval. Outcome of the UPS and general health perception at follow-up were used as major outcome variables. RESULTS: Outcome of the UPS and general health perception at follow-up were not strongly associated with each other. More than half (63%) of the patients reported improvement of their initial symptoms, but only 38% of the patients considered themselves at follow-up to be in good health. UPS outcome was predominantly predicted by the duration of the UPS and the number of additional physical symptoms at baseline. General health perception at follow-up was predominantly predicted by the general health perception at baseline and the number of additional physical symptoms and pain experience at baseline. The explained variance of the general health perception was three times as high as the explained variance for the UPS outcome. Alexithymia was not associated with any of the two outcome variables. CONCLUSIONS: Outcome of the UPS and general health perception at follow-up are not strongly associated and are predicted by different variables. Alexithymia, however, is not an important predictor for the outcome in the majority of UPS patients.

Childhood adversities as risk factors for alexithymia and other aspects of affect dysregulation in adulthood.

BACKGROUND: Affect regulation is assumed to be a biologically based function that can become disrupted by inadequate parenting and by traumatic experiences. We studied the relation between the perceived parental parenting style, and sexual and physical abuse, with alexithymia, dissociation, anxiety and depression. METHODS: In a cross-sectional study psychiatric outpatients were administered a structured interview on childhood physical and sexual abuse and they completed a number of questionnaires about the parenting styles of their parents, and about alexithymia, dissociation and mood pathology. RESULTS: Maternal and paternal parenting styles were moderately correlated with alexithymia and depression. The paternal parenting style was also correlated with dissociation. Optimal parenting of one of the parents had a buffering effect on the degree of alexithymia, but not on the severity of other forms of affect dysregulation. The effect of sexual or physical abuse did not add to that of parental parenting style in terms of predicting affect dysregulation. However, a positively perceived maternal parenting style was found to have a buffering effect in terms of the degree of alexithymia, if sexual abuse had also taken place. CONCLUSIONS: Perceived parenting does appear to be of some significance in the development of alexithymia. Optimal parenting of one of the parents may protect against the development of alexithymia when the parenting of the other parent is perceived as non-optimal. However, it is likely that other factors besides parental care and sexual or physical abuse play an important role in the development of an adequate affect regulation.