Couples Therapy & Attachment Theory

Couples Therapy

• Psychotherapy designed to aid couples in understanding and resolving conflicts and to improve their relationships
• Focuses on improving communication, enhancing emotional connection, and addressing conflicts

Attachment Theory (John Bowlby)

• Attachment styles develop from early caregiver interactions and influence future relationships
• Attachment styles shape perceptions of relationships, trust, and emotion regulation

Secure Attachment

• Caregivers are consistently responsive
• Leads to trust and confidence in relationships

Anxious Attachment

• Caregivers are inconsistent, creating clinginess
• Includes fear of abandonment and emotional dependency

Avoidant Attachment

• Caregivers are emotionally distant or neglectful
• Leads to emotional self-reliance and difficulty trusting others

Disorganized Attachment

• Caregivers are abusive or unpredictable
• Leads to fear, confusion, and unstable relationships

Relationship Dynamics (John Gottman)

• Key negative communication patterns predict relationship breakdown if unchecked

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 instead of addressing concerns
• Stonewalling: shutting down emotionally and withdrawing from the conversation

Managing Conflicts

• Use soft startups (kindness rather than accusation)
• Accept influence (open instead of defensive)
• Repair attempts (humor, touch, kind words to de-escalate)
• De-escalate emotional flooding (take breaks when overwhelmed)
• Compromise

Building Intimacy

• Enhance love maps
• Express fondness and admiration
• Turn toward instead of away
• Create shared meaning (build rituals, traditions, and goals together)
• Make time for each other

Theoretical Frameworks

• Psychodynamic: Focuses on unresolved internal conflicts and their effect on present relationships
• Cognitive Behavioral: Focuses on identifying and 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 where individual behavior is shaped by family and social dynamics

Common Issues in Couples Therapy

• Miscommunication is one of the most common issues in couple's therapy
• Conflict resolution strategies can help couples identify their conflict styles (e.g., avoidance, confrontation, or compromise)
• Intimacy and sexual issues may include addressing mismatched sexual drives, unresolved sexual trauma, or exploring emotional intimacy concerns
• Rebuilding trust and emotional safety is required after breaches of trust, such as cheating
• Financial conflicts involve exploration how financial issues, budgeting, and unequal contributions lead to relationship stress
• Parenting disagreements arise from differing parenting styles or views on having children

The Role of the Therapist

• Therapists should avoid taking sides and work to mediate discussions between partners impartially
• Therapists identify hidden dynamics by recognizing the surface issue may not be the core problem
• Therapists facilitate communication by teaching couples to better understand each other’s perspectives and emotional needs
• Boundary setting involves teaching couples how to maintain healthy boundaries with each other, especially if codependency is a problem

Therapeutic Models in Couples Therapy

• Emotionally Focused Therapy (EFT) focuses on strengthening emotional bonds by addressing attachment insecurities to move couples to more secure, loving exchanges
• Gottman Method involves building love maps to help partners gain detailed knowledge of each other’s world (likes, dislikes, fears, values, important life events, daily routines, stressors, goals)
• Managing Conflict involves teaching techniques for handling inevitable conflicts in a respectful and constructive way
• Creating Shared Meaning helps couples develop shared goals, rituals, and values
• Cognitive Behavioral Therapy (CBT) aims to help couples identify negative thoughts and cognitive distortions contributing to relationship problems
• Imago Relationship Therapy focuses on how unresolved childhood wounds affect adult relationships
• By understanding their "imago" (subconscious image of what love should look like based on childhood experiences) couples can heal and grow together

Assessment Tools in Couples Therapy

• Dyadic Adjustment Scale (DAS): Widely used measure to assess quality and satisfaction in a relationship
• Gottman Relationship Checkup: online tool to assess strengths and challenges based on the Gottman Method
• Communication Pattern Questionnaire (CPQ): Assesses patterns of communication to predict future relationship problems
• Five Love Languages Quiz: Helps couples identify how they best receive and express love (e.g., words of affirmation, acts of service, physical touch, etc.)

Stages of Therapy

• Assessment and Goal Setting includes an in-depth assessment of the couple’s history, backgrounds, and key issues to set goals for therapy
• Conflict Resolution Phase helps the couple work on resolving ongoing conflicts with tools facilitated by the therapist to model healthy behavior
• Building Positive Interaction helps couples focus on improving intimacy and positive interactions once conflict resolution starts
• Maintenance and Relapse Prevention helps couples build long-term relationship improvement skills; may involve booster sessions or check-ins

Dealing with Complex Issues

• Couples may have underlying trauma that affects their behavior in relationships
• Integration of trauma-informed care assists partners in recognizing how their trauma impacts dynamics
• Mental Health and Addiction require therapist-coordinated intervention with individual therapists or addiction specialists
• Domestic Violence cases puts safety as the priority, resulting in possible referrals due to couples therapy not being recommended in active abuse situations

Important Considerations

• Divorce Counseling: If reconciliation isn’t possible, work with couples to process the end of the relationship in a healthy manner with focus on co-parenting if necessary
• Cultural Norms and Values: Therapists should be culturally sensitive and aware of how different cultural backgrounds influence relationship dynamics, gender roles, and expectations
• Gender, Sexual Orientation, and Identity: LGBTQ+ couples face issues around sexual orientation, gender identity, and societal pressures that may be additional stressors in the relationship

Outcome and Follow-up

• Use session notes, outcome measures (satisfaction surveys), and self-reports to track progress
• Long-term success involves continual work after therapy along with developing and reviewing long-term goals

Eating Disorders

• Serious mental health conditions involving preoccupations with food, body weight, and shape
• Cause dangerous behaviors that negatively affect physical and mental health

Classification of Eating Disorders (DSM-5 Criteria)

• Anorexia Nervosa (AN): Characterized by intense fear of gaining weight, significant restriction of food intake, leading to a markedly low body weight (BMI)
• Subtypes: Restricting type vs. binge-eating/purging type
• Physical Complications: Include osteoporosis, amenorrhea, bradycardia, and hypotension
• Psychiatric Comorbidities: Include depression, anxiety, and obsessive-compulsive traits

Bulimia Nervosa (BN)

• Core Features: Recurrent episodes of binge eating followed by inappropriate compensatory behaviors (e.g., vomiting, excessive exercise, laxative use)
  • Normal/above normal BMI with strong concern about body shape/weight but without being underweight
  • Not as extreme as AN or AN-BP
  • Menstrual cycle usually not affected
• Diagnostic Criteria: Binge and compensatory behaviors occur at least once a week for three months.
  • Physical Complications: Electrolyte imbalances, esophageal tears, dental erosion
  • Psychiatric Comorbidities: Mood disorders and substance abuse

Binge Eating Disorder (BED)

• Core Features: Recurrent episodes of eating large quantities of food in a short period
• Accompanied by a sense of loss of control and guilt, but without compensatory behaviors
  • Prevalence: More common than anorexia and bulimia
  • Complications: Obesity, metabolic syndrome, cardiovascular risks
  • Psychiatric Comorbidities: Depression, anxiety, impulsivity

Other Specified Feeding or Eating Disorder (OSFED)

• Includes clinically significant eating disorders that do not meet full criteria for AN, BN, or BED (e.g., atypical anorexia nervosa, purging disorder)

Avoidant/Restrictive Food Intake Disorder (ARFID)

• Characterized by avoidance of certain foods due to sensory characteristics, concerns about choking, or lack of interest in eating
  • Complications: Nutritional deficiencies and stunted growth in children

Epidemiology of Eating Disorders

• AN: 0.5-1% lifetime prevalence in females; significantly lower in males
• BN: 1-2% in women; lower in men
• BED: Affects about 2-3% of the general population
• Eating disorders are more common in women, but the prevalence among men is rising
• Age of Onset: Typically begins in adolescence/early adulthood, though can occur at any age.
• Westernized ideals contribute to to a higher prevalence in certain cultures, but eating disorders are seen worldwide

Etiology and Risk Factors

• Twin studies show heritability, especially for anorexia nervosa
  • Dysregulation in serotonin and dopamine pathways; abnormalities in the hypothalamus affecting hunger and satiety
  • Changes in leptin produced by adipose tissue that helps regulate body weight and energy balance
  • Ghrelin produced in the stomach that plays a role in regulating appetite and food intake (hunger hormone)
  • Cortisol produced in adrenal glands and may be increased due to chronic food restriction

Psychological Factors

• Cognitive Distortions: Overvaluation of body shape and weight, perfectionism, rigid thinking
• Trauma: History of childhood trauma, abuse, or neglect increases vulnerability
• Personality Traits: Those with eating disorders often exhibit high levels of impulsivity, harm avoidance, and obsessive-compulsive traits

Sociocultural Factors

• Cultural Pressures: Media influence and societal standards of beauty emphasizing thinness
• Family Dynamics: Family conflict, enmeshment, overprotectiveness, or parental criticism
• Peer Influence: Peer pressure and bullying related to body image concerns

Neurobiology of Eating Disorders

• Hypothalamus: Dysregulation in appetite control
• Insular Cortex: Altered interoceptive awareness
• Reward System: Altered dopamine functioning in the reward pathway, particularly in BN and BED.
• Serotonin Dysfunction: Linked to satiety, mood regulation, and impulse control in AN and BN

Clinical Features and Presentation

• AN: Severe weight loss, lanugo, cold intolerance, brittle nails, and hair thinning
• BN: Normal or slightly above normal weight, parotid gland enlargement, calluses on knuckles (Russell’s sign), and dental erosion
• BED: Overweight or obese, no physical signs of purging or compensatory behaviors
• Preoccupation with food, calories, or dieting
• Ritualistic eating habits (e.g., cutting food into small pieces)
• Social withdrawal and avoidance of eating with others
• Distorted body image
• Fear of gaining weight (AN)
• Shame, guilt, or secrecy around eating behaviors (BN, BED)

Assessment and Diagnosis

• Medical Assessment: Vital signs, BMI, laboratory tests (electrolytes, thyroid function, liver enzymes)
• Psychiatric Assessment: Screening for comorbid mood disorders, anxiety, OCD, and PTSD

Eating Disorder Inventories:

• Eating Disorder Examination Questionnaire (EDE-Q)
• SCOFF Questionnaire (rapid screening tool)
• Body Image Assessment Tools
• Laboratory and Imaging: Blood tests (e.g., CBC, electrolytes), ECG (for arrhythmias), DEXA scan (bone density in AN)

Complications and Medical Consequences

• Cardiovascular: Bradycardia, hypotension, arrhythmias, and sudden death (especially in AN)
• Endocrine: Amenorrhea, hypoglycemia, thyroid dysfunction, and osteoporosis (AN)
• Gastrointestinal: Gastroparesis, constipation, and esophageal tears (BN)
• Renal: Electrolyte disturbances (hypokalemia, hyponatremia)
• Neurological: Seizures, cognitive impairment, and peripheral neuropathy

Treatment Modalities (Psychotherapy)

• Cognitive Behavioral Therapy (CBT): Gold standard for BN and BED, focuses on modifying distorted thoughts around body image and food
• Dialectical Behavioral Therapy (DBT): Addresses emotional regulation and impulsivity in BN and BED
• Family-Based Treatment (FBT): Particularly effective for adolescents with AN, involves empowering families to take control of the patient’s eating behaviors
• Interpersonal Therapy (IPT): Focuses on improving interpersonal relationships, which can reduce disordered eating behaviors

Pharmacotherapy

• SSRIs: Especially fluoxetine (Prozac) for BN helps reduce binge-purge cycles, may assist in treating depression in AN and BED
• Atypical Antipsychotics: E.g., olanzapine, used off-label to promote weight gain in AN and to reduce obsessive thinking about weight
• Topiramate: May help reduce binge eating and weight gain in BED
• Lisdexamfetamine (Vyvanse): FDA-approved for moderate to severe BED

Nutritional Rehabilitation

• Supervised meal plans, gradual refeeding for AN to avoid refeeding syndrome ,a dangerous shift in fluids and electrolytes leading to cardiac and respiratory failure
• Dietitian involvement for meal planning and education -

Prognosis and Long-Term Outcomes

• Hospitalization Criteria: Severe malnutrition (BMI < 15), medical instability (electrolyte imbalances, bradycardia), suicidality, or failure of outpatient treatment
• Recovery Rates:
  • AN: 50-70% recovery, but high rates of chronicity and relapse
  • BN: Higher recovery rates than AN, with 70-80% showing significant improvement
  • BED: Typically more favorable outcome with appropriate treatment
• Relapse: High relapse rates, particularly in AN. Long-term follow-up is critical
• Mortality: AN has the highest mortality rate of any psychiatric disorder, due to medical complications or suicide

Trauma

• Trauma-related and stressor-related disorders are mental health conditions triggered by exposure to traumatic or highly stressful life events
• Individuals experience maladaptive emotional and behavioral responses, often including anxiety, fear, dissociation, avoidance, and hypervigilance
• These disorders range from short-term stress responses to chronic, debilitating conditions like PTSD or Dissociative Identity Disorder

PTSD

• Develops after experiencing or witnessing a life-threatening event such as combat exposure, sexual assault, serious accidents, natural disasters, terrorist attacks, or childhood abuse/neglect
• Characterized by intrusive memories, emotional distress, avoidance behaviors, and hyperarousal

DSM-5 Diagnostic Criteria

• To be diagnosed with PTSD, the individual must exhibit symptoms for more than 1 month in four categories

Intrusion Symptoms

• Recurrent, involuntary, and distressing memories of the trauma.
• Flashbacks (feeling as if the trauma is happening again)
• Nightmares related to the trauma
• Intense emotional or physical reactions to trauma reminders

Avoidance Symptoms

• Efforts to avoid thoughts, memories, or conversations about the traumatic event
• Avoiding places, people, or situations associated with the trauma
• Emotional numbing and detachment from others

Negative Alterations in Cognition & Mood

• Persistent negative beliefs about oneself, others, or the world
• Distorted blame of self or others for the trauma.
• Inability to experience positive emotions
• Loss of interest in activities

Hyperarousal Symptoms

• Irritability and anger outbursts
• Hypervigilance (constantly feeling “on edge”)
• Exaggerated startle response
• Difficulty concentrating and sleep disturbances

Risk Factors

• Pre-Trauma Factors: Pre-existing mental health disorders, genetic predisposition to anxiety disorders, and childhood adversity
• Peri-Trauma Factors: Severity of trauma and level of perceived life threat
• Post-Trauma Factors: Lack of social support, repeated exposure to trauma reminders, and maladaptive coping strategies (substance abuse, avoidance)

Treatment Approaches

• Medications: SSRIs (first-line treatment), prazosin (treats PTSD-related nightmares), and mood stabilizers/atypical antipsychotics (for severe agitation)
• Psychotherapy:
  • Cognitive-Behavioral Therapy (CBT): Helps reframe negative thoughts with regards to catastrophizing and overgeneralization
  • Prolonged Exposure Therapy: Reduces avoidance behaviors with goals to reduce fear, desensitize the traumatic memory, correct maladaptive behaviors, and regain sense of control via imaginal/real-life exposure and cognitive processing
    • Eye Movement Desensitization and Reprocessing (EMDR) processes traumatic memories using guided eye movements
• Social Support: Reduces perceived threat and isolation, enhances emotional processing (prevents ruminations), and encourages healthy coping strategies (opposed to avoidance or substance abuse)

Acute Stress Disorder (ASD)

• Similar to PTSD, but occurs within 3 days to 1 month after trauma
• Symptoms: Dissociative symptoms, intrusive thoughts/flashbacks/nightmares, avoidance of trauma-related stimuli, hyperarousal, and emotional numbing/amnesia
• Treatment: Short-term crisis intervention, trauma-focused CBT, and SSRIs/short-term benzodiazepines (for severe anxiety)

Adjustment Disorder

• Maladaptive emotional/behavioral responses to a stressfdul life event, occurring within 3 months
• Unlike PTSD, there is no requirement for a life-threatening event
• Symptoms: Depression/anxiety/anger/conduct problems, sleep disturbances/withdrawal, excessive worry/hopelessness, and impaired daily functioning
• Treatment: Cognitive-behavioral therapy (CBT), supportive therapy/counseling