The prevalence of personality disorder in community mental health care appears to be substantial, but better estimates will only emerge from high quality studies with greater consistency of method. Implementing screening tools within outpatient or community services may result in high rates of personality disorder identification, with both clinical and service implications.
Attachment concepts are used in diverging ways, which has caused confusion in communication among researchers, among practitioners, and between researchers and practitioners, and hinders their potential for collaboration. In this essay we explore how attachment concepts may vary in meaning across six different domains: popular discourses, developmental science, social psychological science, psychiatric diagnosis, psychotherapy, and child welfare practice. We attempt to typify these forms of attachment discourse by highlighting points of convergence, divergence, and relay between the different domains. Our general conclusions are that diversity in the use of attachment concepts across different domains of application has been largely unrecognised, and that recognition of these differences would reduce confusion, help identify sites where infrastructure needs to be developed to support coordination, and strengthen opportunities for collaboration to mutual benefit. We suggest that academic attachment discourse would benefit from clarification of core terminology, including: "attachment", "internal working model", "trauma", and "dysregulation".
Children and young people who are adopted from care, in care, or at risk of going into care are at higher risk of attachment difficulties and disorders. This may increase the likelihood of mental health conditions and poor emotional regulation. GPs play a role in managing this risk in the community in conjunction with a multi-disciplinary team and supporting referrals to secondary care. However, many GPs are unfamiliar with the terminology of attachment difficulties, attachment disorders, secure attachment and insecure attachment. This article aims to explain these terms and provide an update for GPs on the implications of the National Institute for Health and Clinical Excellence guidelines on child attachment, which focuses on looked after children.
Clinical practitioners are frequently encouraged, through literature, training, and policy, to learn, understand, refer to and use their knowledge of attachment theory and research when working to meet the needs of children and families. However, there has been very little empirical study of how practitioners understand and perceive the relevance of attachment concepts and methods. Q-methodology was used to examine the perceptions of attachment knowledge and its applications for practice among 30 UK clinicians working with children and an international group of 31 attachment researchers. Factor analysis revealed three perspectives, described as: i) pragmatic, developmental, and uncertain, ii) academic, and iii) autodidactic and therapeutic. Participants agreed on core tenants of theory, their aspirations for clinical practice and the inaccessibility of current assessment measures for practitioners. Yet they diverged on their understandings of attachment insecurity, disorganisation, and the implications of both for various aspects of child development.
What might clinicians make of Bowlby’s first patient if he were seen by services today? How might thinking with Bowlby help us critically consider children whose presentations span a number of diagnoses, and children who do not readily fit any existing diagnostic category? We will consider these questions through exploration of Bowlby’s writings, as well as review of the literature on diagnosis, trauma, and caregiving environments. We identify tensions between the three key legacies of Bowlby’s work: the focus on family systems; attachment theory as a theory of individual development; and psychiatric classification of attachment. In doing so, we will use conversation with Bowlby’s ideas as the basis for a consideration of the purpose and function of diagnosis.
Background: Hoarding disorder (HD) can be understood through the cognitive behavioural model in the context of vulnerability factors (for example, personality traits, co-morbidities, traumatic life events) and beliefs about possessions (for example, identity, emotional attachment, memory, utility). Less is known about the strength of these hypothesised beliefs, or how they interact within the hoarding population, with researchers suggesting that specifying beliefs would improve treatment outcomes. Aim: The current study explored beliefs in HD, utilising Q-methodology to explore both categories of beliefs and the interactions between these. Moreover, Q-methodology allowed for comparison of the individuals endorsing specific categories of beliefs. Method: A comprehensive list of beliefs about possessions was developed. Thirty-two adults with clinically significant levels of HD completed a Q-sort task, alongside measures of proposed vulnerabilities, including co-morbidity, trauma and attachment style. Results: Q-factor analysis produced four profiles consisting of groups of participants who endorsed the same beliefs and had shared characteristics: (1) ‘Expression of identity’, (2) ‘Responsibility and morality’, (3) ‘Stability and predictability’, and (4) ‘Objects as emotional and meaningful beings’. Discussion: The profiles were distinguished by different categories of beliefs and co-morbid symptoms, suggesting that more targeted assessment tools and interventions would be beneficial to account for this heterogeneity within the clinical population. In particular, beliefs about identity and self-concept formed the largest profile, and beliefs about stability and predictability introduce a novel category of beliefs.
Numerous meta-analyses have established associations between child maltreatment and mental health. However, variation exists between reviews regarding the magnitude of these predictions. A systematic, quantitative umbrella synthesis (i.e. meta-analysis of meta-analyses) was undertaken to describe the associations between various types of maltreatment (i.e. physical abuse, emotional abuse, sexual abuse, neglect, prenatal substance misuse, adverse childhood experiences and intimate partner violence) and mental health issues including executive functioning. We analysed and combined effect sizes from 97 quantitative meta-analyses comprising more than 11 million participants, published between January 1, 2016, and July 19, 2021. Child maltreatment was associated with all examined outcomes: 1) externalizing problems (r = 0.21), 2) internalizing problems (r = 0.21), 3) thought problems (r = 0.33), 4) executive functioning (r = 0.23), 5) suicide and related behaviors (r = 0.24), 6) substance misuse (r = 0.20), 7) interpersonal violence (r = 0.25) and 8) other psychological difficulties (r = 0.22). Findings demonstrate that maltreatment is associated with various psychological difficulties, and these associations tend to be of similar magnitude for different forms of maltreatment. A parsimonious explanation for these findings would be a common mechanism(s) or a general psychopathology factor conferring high risk for different mental health problems following child maltreatment. For practitioners and service providers, these results indicate a comparable degree of mental health difficulties across all forms measured in the wake of maltreatment. The results call into question the conventional wisdom that suggests some forms of maltreatment are intrinsically more harmful to mental health than others.
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