Preventing Adverse Outcomes for Bereaved Youth: Indirect Effects From a Randomized Trial of the Family Bereavement Program on Fear of Abandonment, Grief, and Mental Health.

OBJECTIVES: We investigated whether the self-system belief of fear of abandonment mediated the effects of intervention-induced change in 2 protective factors-positive parenting and adaptive coping-and one risk factor-stressful events-on youth mental health problems and maladaptive grief. This study extends prior research on fear of abandonment in youth who experience parental death by examining pathways through which a program reduced fear of abandonment and, in turn, affected subsequent pathways to child mental health problems in the context of a randomized experiment. METHODS: This is a secondary data analysis study. We used data from the 4-wave longitudinal 2-arm parallel randomized controlled trial of the Family Bereavement Program conducted between 1996 and 1999 in a large city in the Southwestern United States. The sample consisted of 244 offspring between 8 and 16 at the pretest. They were assessed again at posttest, 11-month follow-up, and 6-year follow-up. Offspring, caregivers, and teachers provided data. RESULTS: Mediation analyses indicated that intervention-induced reductions in stressful events were prospectively associated with a lower fear of abandonment. For girls, fear of abandonment was related to self-reported maladaptive grief and teacher-reported internalizing problems 6 years later. CONCLUSIONS: This study extends prior research on the relation between intervention-induced changes in risk and protective factors and improvements in outcomes of bereaved youth. The findings support the reduction of stressful events as a key proximal target of prevention programs for bereaved children.

One Year of Outpatient Dialectical Behavioral Therapy and Its Impact on Neuronal Correlates of Attachment Representation in Patients with Borderline Personality Disorder Using a Personalized fMRI Task.

(1) Background: BPD is characterized by affect dysregulation, interpersonal problems, and disturbances in attachment, but neuroimaging studies investigating attachment representations in BPD are rare. No study has examined longitudinal neural changes associated with interventions targeting these impairments. (2) Methods: We aimed to address this gap by performing a longitudinal neuroimaging study on n = 26 patients with BPD treated with Dialectic Behavioral Therapy (DBT) and n = 26 matched healthy controls (HCs; post intervention point: n = 18 BPD and n = 23 HCs). For functional imaging, we applied an attachment paradigm presenting attachment related scenes represented in drawings paired with related neutral or personalized sentences from one's own attachment narratives. In a prior cross-sectional investigation, we identified increased fMRI-activation in the human attachment network, in areas related to fear response and the conflict monitoring network in BPD patients. These were especially evident for scenes from the context of loneliness (monadic pictures paired with individual narrative sentences). Here, we tested whether these correlates of attachment representation show a near-to-normal development over one year of DBT intervention. In addition, we were interested in possible associations between fMRI-activation in these regions-of-interest (ROI) and clinical scores. (3) Results: Patients improved clinically, showing decreased symptoms of borderline personality organization (BPI) and increased self-directedness (Temperament and Character Inventory, TCI) over treatment. fMRI-activation was increased in the anterior medial cingulate cortex (aMCC) and left amygdala in BPD patients at baseline which was absent after intervention. When investigating associations between scores (BPI, TCI) and functional activation, we found significant effects in the bilateral amygdala. In contrast, aMCC activation at baseline was negatively associated with treatment outcome, indicating less effective treatment effects for those with higher aMCC activation at baseline. (4) Conclusions: Monadic attachment scenes with personalized sentences presented in an fMRI setup are capable of identifying increased activation magnitude in BPD. After successful DBT treatment, these increased activations tend to normalize which could be interpreted as signs of a better capability to regulate intensive emotions in the context of "social pain" towards a more organized/secure attachment representation. Amygdala activation, however, indicates high correlations with pre-treatment scores; activation in the aMCC is predictive for treatment gain. Functional activation of the amygdala and the aMCC as a response to attachment scenes representing loneness at baseline might be relevant influencing factors for DBT-intervention outcomes.

Neural Correlates of Attachment Representation in Patients With Borderline Personality Disorder Using a Personalized Functional Magnet Resonance Imaging Task.

Background: Fear of abandonment and aloneness play a key role in the clinical understanding interpersonal and attachment-specific problems in patients with borderline personality disorder (BPD) and has been investigated in previous functional Magnet Resonance Imaging (fMRI) studies. The aim of the present study was to examine how different aspects of attachment representations are processed in BPD, by using for the first time an fMRI attachment paradigm including personalized core sentences from the participants' own attachment stories. We hypothesized that BPD patients would show increased functional involvement of limbic brain regions associated with fear and pain (e.g., the amygdala and the anterior cingulate cortex) when presented personalized attachment relevant stimuli representing loneliness compared to healthy controls (HC). Methods: We examined the attachment classifications of 26 female BPD patients and 26 female HC using the Adult Attachment Projective Picture System (AAP). We used an fMRI-adapted attachment paradigm to investigate the neural correlates of attachment. All participants were presented three personalized (vs. neutral) sentences extracted from their AAP attachment narrative, combined with standardized AAP pictures representing being alone (monadic) or in interactive (dyadic) attachment situations. Results: As expected, the classification of unresolved attachment was significantly greater in BPD compared to HC. BPD patients showed increased fMRI-activation in brain areas associated with fear, pain, and hyperarousal than HC when presented with personalized attachment-relevant alone stimuli. In particular, pictures with monadic attachment situations induced greater anterior medial cingulate cortex, anterior insula, amygdala, thalamus and superior temporal gyrus activation in the patient group. Conclusion: The results point to increased fMRI-activation in areas processing emotional distress and painful experiences in BPD patients. In particular, the emotional cascade reflecting attachment distress was evoked by combining monadic pictures, representing abandonment and aloneness, with the patients' personalized narrative material. Our results confirmed and replicated previous results that illustrate once again the high relevance of aloneness and feelings of abandonment for BPD in the context of attachment trauma. Moreover, our results support the hypothesis of hypermentalization in response to attachment distress as a core feature of social-cognitive impairment in BPD associated with common treatment implications across different therapeutic orientations.

Crimes of passion: When romantic obsession leads to abusive relationships.

OBJECTIVE: This research examines the relationship between passion for a romantic partner and obsessive relational intrusion (ORI) which is defined as repeated and unwanted behaviors toward a partner that invade his/her personal privacy and cause fear for his/her safety. METHOD: Based on the dualistic model of passion, we predicted that obsessive passion (OP) would be associated with fear of abandonment, which in turn would be associated with ORI. In contrast, harmonious passion (HP) should not be associated with ORI. RESULTS: Four studies (N = 1257) supported these predictions. Study 1 found cross-sectional support for these hypotheses from the victim's perspective. Study 2 replicated Study 1 and extended it to the perpetrator's perspective by demonstrating that the relationship between passion and ORI is mediated by fear of abandonment. Study 3 replicated these findings using an experimental manipulation of passion. Study 4 found similar results by experimentally manipulating fear of abandonment, the mediator, to demonstrate its causal influence on ORI. CONCLUSIONS: Taken together, the present results demonstrate that passion and fear of abandonment play an important role in the type of behavior people are willing to pursue to maintain their romantic relationship.

Reviewing the clinical significance of 'fear of abandonment' in borderline personality disorder.

OBJECTIVES:: To review and highlight the clinical significance of the symptom 'fear of abandonment' in borderline personality disorder (BPD). METHODS:: A systematic search of the literature was conducted using MEDLINE and PubMed, employing search terms including 'fear of abandonment', 'borderline personality disorder' and 'rejection'. The most relevant English-language articles and books were selected for this review. RESULTS:: Fear of abandonment is widely recognised as a core symptom in BPD; a biopsychosocial explanation for the occurrence of the symptom is presented. While fear of abandonment may differ in its clinical presentation, it has a significant impact on therapeutic engagement, suicidal behaviour and non-suicidal self-injury, clinical management and prognosis. Most evidence based psychotherapies for BPD address the phenomenon of fear of abandonment; however, the lack of specifically targeted treatment interventions is disproportionate to its prominence and clinical significance. CONCLUSIONS:: Given its defining role in BPD, we recommend fear of abandonment as an important subject of future research and a specific therapy target.

Attachment styles in patients with avoidant personality disorder compared with social phobia.

OBJECTIVES: Avoidant personality disorder (AvPD) and social phobia (SP) are common, closely related conditions. Little is known about the underlying processes related to the social discomfort of subjects with AvPD and SP. Both disorders are associated with interpersonal problems. An attachment perspective may shed light on similarities and differences in close relationships between the disorders. The aim of the study was to compare self-reported attachment styles in patients with AvPD and SP. We expected that patients with AvPD would have more attachment anxiety and avoidance and more often a Fearful attachment style, compared with SP. DESIGN: This is a cross-sectional multisite study of 90 adult patients with AvPD and SP. Patients with AvPD with and without SP (AvPD group) were compared with patients with SP without AvPD (SP group). METHODS: Patients were assessed using structured diagnostic interviews and self-reporting questionnaires, including Experiences in Close Relationships (ECR). The ECR dimensions, Anxiety and Avoidance, and the new described five factors of the ECR were used. RESULTS: The AvPD group had higher levels of attachment anxiety than the SP group, especially for the sub-factors Anxiety for abandonment and Separation frustration. The diagnostic groups did not differ in levels of avoidance. Anxiety for abandonment was still associated with AvPD after controlling for symptom disorders and the criteria of other personality disorders. A Fearful attachment style was more frequent among patients with AvPD. CONCLUSIONS: The results indicate AvPD is associated with more attachment anxiety than SP. Fear of abandonment may play a significant role in the AvPD pathology. PRACTITIONER POINTS: This is the first study to compare attachment styles in patients with avoidant personality disorder (AvPD) and social phobia (SP). The AvPD group had higher attachment-related anxiety than the SP group, and anxiety was most pronounced for the fear of abandonment. Fear of abandonment may play an important role in the AvPD pathology.

Difference in the timing of cessation of palliative chemotherapy between patients with incurable cancer receiving therapy only in a local hospital and those transitioned from a tertiary medical center to a local hospital.

BACKGROUND: It is important to know when to decide to end palliative chemotherapy (PC) for the quality of life of patients. However, there is currently no clear agreement on when to terminate PC. OBJECTIVES: To determine whether the difference of the period between the completion of PC and death affects patients' trajectory of supportive care near end of life. METHODS: This retrospective study included 52 adult patients with incurable cancer who had received PC and who were referred to our palliative care team and died in our local hospital between July 2011 and June 2014. Group A comprised patients who received anticancer therapy such as surgery and PC only in our hospital and eventually died there. Group B comprised patients who were transitioned to our hospital from tertiary medical centers after cessation of PC. RESULTS: 17 of 22 patients (77%) in Group A conveyed the intention of continuing PC in the first interview with a physician of the palliative care team, whereas 4 of 30 patients (13%) in Group B conveyed a similar intention. The patients in Group B stopped PC a median of 43 days earlier than did the patients in Group A (𝑃 < .0001). CONCLUSIONS: These data showed that more patients in Group A wanted to continue PC and had a shorter interval between last PC and death. Change in the hospital where the patients are given supportive care might contribute to the cessation of futile PC at an appropriate time.

Cuidar no como una buena madre: análisis de un niño de 5 años con serios problemas de conducta / Taking care not like a good mother: analysis of a five-year-old child with a serious conduct problem

Existen formas de maltrato infantil que culturalmente no se consideran como tales por ser aparentemente inofensivas, pero que Raskovsky (1975[1970]) llama formas atenuadas del filicidio. Aunque sus efectos varían de acuerdo con las circunstancias particulares, puede suponerse que para el aparato psíquico representan un exceso de Qή (Freud, 1895) que debe expulsar por cualquier medio: a menudo, conductas agresivas. Aquí se presenta el caso de un niño de 5 años sometido al enojo de la madre, quien lo dejaba inerme ante su tensión o la intensificaba con sus regaños, dejándolo así sin la posibilidad de metabolizar dicha tensión. En este trabajo se analiza la historia del niño y sus producciones en sesiones de observación y tratamiento siguiendo la línea de Bleichmar (1993, 1999).

There are forms of child mistreatment that culturally are not considered as such by being seemingly harmless, but Raskovsky (1975[1970]) called them attenuated forms of filicide. Although its effects vary according to particular circumstances, it may be supposed that it means an excess of Qή (Freud, 1895) for the psychic apparatus that must be drained out anyhow: often, through aggressive behavior. Here we report the case of a 5 years old boy exposed to the mother’s anger; she left him helpless against his tension states or intensified them through her scolding, leaving no chance to metabolize the tension. This paper analyzes the child history and his productions through observation ant treatment sessions following Bleichmar’s (1993, 1999) views.