Couples Therapy and Attachment Styles

Couples Therapy

• A psychotherapy that helps couples understand and resolve conflicts to improve their relationships
• It focuses on improving communication, enhancing emotional connection, and addressing conflicts

John Bowlby's Attachment Theory

• Attachment styles develop from early caregiver interactions, influencing future relationships
• These styles shape perceptions of relationships, trust, and emotional regulation

Attachment Styles

• Secure Attachment: Consistently responsive caregivers lead to trust and confidence
• Anxious Attachment: Inconsistent caregivers lead to clinginess, fear of abandonment, and emotional dependency
• Avoidant Attachment: Emotionally distant or neglectful caregivers result in emotional self-reliance and difficulty trusting
• Disorganized Attachment: Abusive or unpredictable caregivers lead to fear, confusion, and instability

John Gottman's Relationship Dynamics

• Identified four negative communication patterns that predict relationship breakdown

The Four Horsemen of the Apocalypse

• Criticism: Attacking a partner's character instead of addressing specific behaviors
• Contempt: Expressing superiority, sarcasm, name-calling, or disrespect
• Defensiveness: Avoiding responsibility and shifting blame
• Stonewalling: Shutting down emotionally and withdrawing

Conflict Management Techniques

• Initiate conversations with kindness rather than accusation
• Being receptive to your partner's opinion instead of defensive
• Use of humor, gentle touch, and kind language to ease situations
• Taking breaks when feeling emotionally overwhelmed
• Compromise

Ways to Build Intimacy

• Strengthen love maps by knowing your partner's inner world
• Express appreciation and fondness
• Choose to connect with your partner instead of withdrawing
• Establish rituals, traditions, and shared goals
• Dedicate quality time to each other

Theoretical Frameworks in Therapy

• Psychodynamic: Addresses unresolved internal conflicts affecting relationships
• Cognitive Behavioral: Focuses on changing maladaptive thought patterns and behaviors
• Humanistic/Existential: Emphasizes emotional self-awareness and personal responsibility
• Systemic: Views the couple as part of a larger system shaped by family and social dynamics

Common Issues in Couples Therapy

• Miscommunication is a main issue
• Conflict resolution strategies assists couples to identify conflict styles (avoidance, confrontation, etc.)
• Intimacy and Sexual issues such as mismatched sexual drives or unresolved sexual trauma
• Infidelity and Trust by rebuilding emotional safety
• Financial conflicts exploring financial stressors and unequal contributions
• Parenting disagreements due to difference in styles

Communication Tools

• Using "I" statements reduces conflict by expressing feelings and needs without blame, promoting emotional awareness and constructive conversation
• Active listening

Role of the Therapist

• Therapists must remain neutral and mediate discussions fairly
• Identifying hidden dynamics to address core issues
• Facilitating effective communication and understanding
• Setting boundaries, especially with codependency

Therapeutic Models

• Emotionally Focused Therapy (EFT): Strengthens emotional bonds by addressing attachment insecurities for more secure exchanges
• Gottman Method: Involves building love maps by gaining detailed knowledge

Assessment Tools

• Dyadic Adjustment Scale (DAS): Measures relationship quality
• Gottman Relationship Checkup: Assesses strengths and challenges
• Communication Pattern Questionnaire (CPQ): Assesses communication patterns
• Five Love Languages Quiz: Identifies ways to express and receive love

Stages of Couples Therapy

• Assessment and Goal Setting: Assess history, set therapy goals, and address key issues
• Conflict Resolution Phase: Resolve conflicts with therapist-provided tools
• Building Positive Interaction: Improve intimacy
• Maintenance and Relapse Prevention: Build skills to maintain improvements

Dealing with Complex Issues

• Trauma is addressed with trauma-informed care
• Mental health and addiction addressed as needed
• Domestic violence focus is on safety first

Other Considerations

• Divorce counseling if reconciliation isn't possible
• Cultural sensitivity regarding cultural norms, gender roles, and expectations
• Consideration of gender, sexual orientation, and identity for LGBTQ+ couples

Outcome Measures and Follow-Up

• Use session notes, outcome measures, and couples' self-reports
• Ensure long-term success through strategies for continued effort and goal review

Eating Disorders

• Serious mental health conditions involving preoccupation with food, weight, and shape
• Behaviors can negatively affect physical mental health

Anorexia Nervosa (AN)

• Features include fear of gaining weight, restricted food intake, and low BMI
• Subtypes are restricting and binge-eating/purging
• Physical complications can include osteoporosis, amenorrhea, bradycardia, and hypotension
• Psychiatric comorbidities can include depression, anxiety, and obsessive-compulsive traits

Bulimia Nervosa (BN)

• Core features are recurrent episodes of binge eating followed by inappropriate compensatory behaviors
• BMI can be normal or above normal
• Menstrual cycle usually unaffected
• Diagnostic criteria binge and compensatory at least once a week for 3 months

Binge Eating Disorder (BED)

• Recurrent episodes of eating large food quantities within a short period
• Include sense of loss of control and guilt but not compensatory behaviors
• Obesity, metabolic syndrome, and cardiovascular risks can be complications
• Psychiatric comorbidities can include depression, anxiety, and impulsivity
• More common than anorexia and bulimia

Other Specified Feeding or Eating Disorder (OSFED)

• Clinically significant eating disorders that do not meet the criteria for AN, BN, or BED

Avoidant/Restrictive Food Intake Disorder (ARFID)

• Characterized by avoiding certain foods due to the sensory characteristics or lack of interest in eating
• Complications include nutritional deficiencies and stunted growth

Epidemiology of Eating Disorders

• AN has a lifetime prevalence of 0.5-1% in women
• BN has a prevalence of 1-2% in women
• BED affects about 2-3% of the general population
• Eating disorders are more common in women
• Typically beings in adolescence and early adulthood
• Westernized ideals of thinness contribute to a higher rate in certain cultures

Etiology and Risk Factors

• Genetics has an association with anorexia nervosa
• Dysregulation of serotonin and dopamine pathways
• Abnormalities in the hypothalamus affects hunger and satiety
• Hormonal dysregulation changes leptin, ghrelin, and cortisol levels

Psychological and Sociocultural Factors

• Cognitive distortions an overvaluation of body shape and weight, perfectionism and rigid thinking
• Individuals with eating disorders often possess traits of high impulsivity, harm avoidance
• Societal ideals that emphasizes thinness
• Trauma, family conflict, overprotectiveness and peer pressure influence

Neurobiology

• Dysregulation in appetite control with the part of the brain called the hypothalamus
• Altered interoceptive awareness with the insular cortex
• Altered dopamine functioning with the reward system
• Altered satiety, mood regulation, and impulse control with serotonin dysfunction

Clinical Presentation (Physical)

• Severe weight loss, lanugo, cold intolerance, hair thinning signs of AN
• Normal weight, parotid gland enlargement signs of BN
• Overweight and obese signs of BED

Clinical Presentation (Behavior and Psych)

• Preoccupation with food, calories, or dieting in terms of behavior
• In terms of psychology there can be a distorted body image and extreme fear of gaining weight
• Shame, guilt, or secrecy around eating behaviors

Assessment and Diagnosis

• A comprehensive evaluation is needed
• Medical assessment
• Psychiatric assessment

Eating Disorder Inventories

• Eating Disorder Examination Questionnaire (EDE-Q)
• SCOFF Questionnaire (rapid screening tool)
• Body Image Assessment Tools

Laboratory and Imaging

• Blood Tests (CBC, electrolytes)
• ECG (for arrhythmias)
• DEXA Scan (bone density in AN)

Complications and Medical Consequences

• Cardiovascular, bradycardia, hypotension, and arrhythmias
• Endocrine, amenorrhea, hypoglycemia, and thyroid dysfunction
• Gastrointestinal, gastroparesis, constipation, and esophageal tears
• Renal, electrolyte disturbances (hypokalemia and hyponatremia)
• Neurological, seizures, cognitive impairment, and peripheral neuropathy

Modalities (Psych, Pharm, Nutrition)

• CBT helps with modifying distortions, best for BN and BED
• DBT helps to regulate emotions, for BN and BED
• FBT is effective for adolescence. empowering families with control
• IPT focuses to improving interpersonal relationships
• SSRIs for help with binge-purge, may assist with depression
• Supervised meal plans, gradual refeeding prevent cardiac conditions
• Get a dietician for meal planning

Hospitalization and Prognosis

• Malnutrition (BMI < 15), medical instability conditions for criteria
• A recovery of AN is 50-70% while BN shows higher recovery at 70-80%
• Mortality in AN is high

Trauma

• Trauma-related and stressor-related disorders triggered by stressful events
• It often includes the maladaptive emotional and behavioral responses
• Acute stress disorder or PTSD are conditions

PTSD

• Trauma (combat exposure, sexual assault, serious accidents) for events
• The person is characterized by trauma reminders, emotional distress and hyperarousal

To be Diagnosed

• Must last more than a month
• The are four categories

Intrusion Symptoms with PTSD

• Distressing memories
• Flashbacks
• Nightmares of the trauma
• Reactions to trauma reminders

Avoidance, Cognitive/Mood, and Hyperarousal with PTSD

• To avoid conversation of the event
• There can be beliefs of oneself that is negative, and inability to experience positive emotions
• Includes irritability and constant vigilance

Risk Factors

• Disorders and childhood adversity
• Severity and perceived threat level
• Repeated exposure to reminders and maladaptive coping strategies

Treatment

• SSRIs or prazosin and mood stabilizers
• CBT or prolonged exposure, and EMDR
• Social Support

Acute Stress Disorder (ASD)

• Happens within 3 days of trauma
• Dissociative symptoms and intrusive thoughts, nightmares
• SSRIs or short-term benzodiazepines

Adjustment Disorder

• Maladaptive responses to stressful life event happening within 3 months
• Stressors can be divorce and financial troubles
• Symptoms range from depression and conduct to sleep disturbances

Treatment

• CBT, therapy, and medication options

Dissociative Disorders

• Involves disruptions in memory and emotion with childhood trauma
• Dissociative amnesia and DID

Dissociative Amnesia

• Inability to recall personal info, different amnestic stages
• Trauma therapy

Dissociative Identity Disorder

• Has two distinct personality states
• Each identity has different memories, therapy can help

Depersonalization/Derealization Disorder

• Feeling detached of oneself (out of body), feels unreal
• CBT or medication can help