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The Perinatal Assessment of Paternal Affectivity (PAPA) (Baldoni et al., 2016, 2018) is a new self-report questionnaire for the screening of affective symptoms in fathers. It has been developed on recent research on perinatal affective disorders and assesses different dimensions of paternal affective problems: anxiety, depression, irritability/anger, relational and couple difficulties, somatic complaints, dangerous behaviors and addictions (smoking, alcohol, drugs, gambling, internet abuse, physical or sexual compulsive and risky behavior). It also considers some ethnic and socio-cultural influences.

The mentalizing processes allow a psychological representation and control of emotions (including related somatic states) and are fundamental for psycho-physiological regulation and for stress management. In all the life difficulties which may interfere with individual development assuming a traumatic value (illness, losses, family conflicts, splitting and divorces, neglect, abuses, dangerous physical experiences, social exclusion, serious economic problems) reflective functions tend to be impaired. In these cases, the representation of the individual self tends to be only somatic and the physiological reaction to stress is out of control. Research has shown that in these individuals somatic symptoms and abnormal illness behavior (hypochondriacal concerns, somatization disorders, functional medical syndromes) can appear, as well as an increased susceptibility to physical or mental illnesses. From the psychological point of view, in fact, these conditions are often characterized by a lack of impulse control (violent or aggressive behavior, panic attacks, fugues, antisocial behavior) or dissociative disorders (amnesia, fugues, depersonalization), expressions of an attempt to protect against traumatic consequences of mental tension. Moreover, subjects with reflexive difficulties tend to manifest compulsive and increasingly extreme behavior (smoking, drinking, taking drugs, eating too much or too little, driving too fast, extreme sports or sexual activities, gambling, excessive use of chat, video games and internet) in an attempt to regulate and control the disturbing emotions in a non-psychological way. The tendency to use these "external regulators of emotions" involves a greater vulnerability to psychic and somatic effects of traumatic experiences and is a feature of many medical illnesses and psychiatric disorders, particularly borderline personality disorders, eating disorder and addictions.

Procedures to assess attachment in school-age are mainly based on verbal responses and are carried out in conditions of relative security, implying some reliability and validity problems. In particular, the assessment in these children presents particular difficulties related to the specific characteristics of this stage of development—such as the different use of verbal and non-verbal communication and the particular display of facial expressions and behaviors related to their inner emotional states. The School-age Assessment of Attachment (SAA) (Crittenden, 1997-2005) is a semi-structured clinical interview that assesses self-protective strategies in children from six to thirteen years following the Dynamic-Maturational Model of attachment and adaptation (DMM). The procedure consists of a set of cards regarding increasing levels of threats that school-age children frequently face. The interview is usually audio recorded, and the classification of the transcript is based on the observation of the child’s behavior and a discourse analysis derived from the Adult Attachment Interview. Adding the video to the transcript improves the classification process by benefiting from para-verbal and non-verbal information— such as the display of false-positive affects in dismissing (Type A) children or the emphasis of negative feelings in preoccupied/coercive (Type C) children, and somatic response. An example of a videotaped SAA of a clinical case will be displayed using Doctor Notes® (Telpress International, 2015), an application originally developed for audiovisual analysis and classification of information that can provide specific tags and a set of buttons for SAA coding. SAA represents a bridge between infant observational procedures and verbal interviews with adults, evidencing the utility of integrating a careful behavioral analysis with the coding process. Using Dr. Notes, the process of transcription based on the video analysis allows a more accurate detection of para-verbal and non-verbal behavior offering researchers and clinicians more information for the attachment classification.

Research on perinatal psychopathology has extensively investigated maternal depression. In recent years, evidence is increasing about the role played by maternal anxiety, in terms of negative consequences on obstetrical and birth outcomes, maternal postnatal adjustment and infant development (Dunkel Schetter, Tanner, 2012). Concerning paternal perinatal psychopathology, only recent literature is showing a growing interest on the study of depression, while anxiety and illness behavior still needs to be further investigated. A prevalence of 20% for anxiety symptoms has been reported in men during their partner's pregnancy (Boyce et al., 2007), with a significant association with woman’s symptoms (Matthey et al., 2003). Besides, paternal prenatal anxiety has been suggested to represent a risk factor for men’s postnatal depression (Edwards et al., 2015). The aim of this talk is to deepen the understanding of perinatal anxiety and somatization in fathers. A brief summary of main findings from international literature on this topic will be presented. Also, data will be shown from two studies, conducted by the authors, on perinatal anxiety in fathers. Both studies focused on: 1) the assessment of perinatal anxiety in fathers from pregnancy to 3 months after birth; 2) the investigation of the relationship between paternal and maternal mood. Differences between the two studies were represented by the investigation on differents dimensions (psychological and physical) of anxiety, and the use of different instruments. The first study focused on stait and trait anxiety and the relationship with pregnancy specific anxieties in mothers. The second study explored general anxiety, somatization, and their relationship with maternal depressive symptoms. In conclusion, few studies have, until now, explicitly assessed paternal perinatal anxiety and illness behavior. This lack of data evidences the need to increase research in this area, as well as the to develop more specific instruments to assess perinatal affective disorders in fathers. References Boyce P, Condon J., Burton J., & Corkindale C. (2007). First-Time Fathers’ Study: psychological distress in expectant fathers during pregnancy. Australian and New Zealand Journal of Psychiatry, 41, 718-25. Dunkel Schetter C, & Tanner L. (2012). Anxiety, depression and stress in pregnancy: implications for mothers, children, research and practice. Current Opinion in Psychiatry, 25(2): 141–148. 9. Edward K., Castle D., Mills C., Davis L., & Casey J. (2015). An integrative review of paternal depression. American Journal of Men’s Health, 9(1), 26-34. Matthey S., Barnett B., Howie P., & Kavanagh D.J. (2003). Diagnosing postpartum depression in mothers and fathers: whatever happened to anxiety? Journal of Affective Disorders, 74(2), 139-47.

During the perinatal period affective alterations in fathers, like Paternal Perinatal Depression, are very frequent, but occur differently than in women (Tuszyńska-Bogucka, & Nawra, 2014; Edward et al. 2015). In particular, depressive symptoms in fathers tend to be less severe, less definite, and often occur in comorbidity with anxiety disorders, alteration of illness behavior and behavioral acting outs like addictions or anger attacks. As a consequence of their indefinite clinical features, these problems are often under-assessed or undiagnosed (Musser et al. 2013). The Perinatal Assessment of Paternal Affectivity (PAPA) is a new questionnaire for the screening of high-risk fathers during the perinatal period. It is based on recent research on perinatal affective disorders and is the first instrument to assess these problems in fathers through many different dimensions: Anxiety, Depression, Hostility, Perceived stress, Relational difficulties, Somatic complaints, Dangerous behavior (driving, sport, at work), Addictions (smoking, alcohol, drugs, internet, gambling) and physiological alteration (sleep, eating). It is fast and simple to administer (one page, five minutes), and ethnic and socio-cultural influences are considered. In this pilot study a sample of 50 Italian fathers assessed during a gynecological consultation at the 8th month of pregnancy of their companion were considered. Besides the PAPA, all subjects were given the following questionnaires: CES-D, EPDS, SCL-90-R, Perceived Stress Scale (PSS) and Dyadic Adjustment Scale (DAS). The preliminary data analysis shows a significant association (P = 0.1) between the scales of Depression, Anxiety, Somatic complaints and Stress perception of the PAPA with the relative scales of CES-D, EPDS, SCL-90-R and PSS. The PAPA is a screening tool, and its goal is not an accurate diagnosis, but it provides a simple and practical guide for detecting fathers at high-risk of perinatal affective alteration, in order to foster a more in-depth diagnostic assessment, and a possible treatment. References Edward K., Castle D., Mills C., Davis L., & Casey J. (2015). An integrative review of paternal depression. American Journal of Men’s Health, 9(1), 26-34. Musser A.K., Ahmed A.H., Foli K.J., & Coddington J.A. (2013). Paternal Postpartum Depression. What Health Care Providers Should Know. Journal of Pediatric Health Care, 27(6), 479-485. Tuszyńska-Bogucka W., & Nawra K.N., (2014). Paternal postnatal depression – a review. Archives of Psychiatry and Psychotherapy, 2, 61–69

One crucial phenomenological aspect in patients with eating disorders is a distressing feeling of emptiness. A void that cannot be filled by any object, that corresponds to the absence of a mental function, the inability to think, to symbolically represent, to attribute meanings, to recognize and communicate fantasies and emotional states. This lack of mentalization is the consequence of the failure of parental reflective capacities and of dysfunctions of attachment and family relationships. A non-psychological way to adjust the mental states is to use external regulators of the emotions, that is, objects, experiences or behaviors that stimulate the body by changing the mental states and somatic functions that accompany them. Children and adults commonly use similar behaviors to calm down, get excited, overcome boredom or distraction, without activating mentalizing psychological processes. People who have difficulty in mentalizing, however, tend to implement, compulsively, intensive and continuous increasingly extreme behavior in an attempt to regulate and control emotions. The behaviors that more frequently assume this significance are smoking, drinking alcohol, taking drugs, overeating (as in bulimic crises or severe obesity) or eating too little (as in anorexia), or intensive, extreme and potentially dangerous physical or sexual activities. These behaviors enable control of disturbing emotional tensions that cannot properly be adjusted by thinking (anxiety, fear, depression, anger, sexual arousal, feelings of helplessness, of emptiness, boredom), as they solicit bodily reactions and opposite emotional tensions (excitement, fear, euphoria, physical pain, hunger, satiety, blunting). The compulsive tendency to use external regulators of emotion, however, represents an important risk factor that affects physical and mental health and is a feature of many psychopathologies, particularly borderline personality disorders, lack of impulse control, addiction and eating disorders.

Psychological trauma is configured as a set of experiences of which it is difficult to make sense. Exposure to hazardous conditions, however, does not necessarily imply a traumatic evolution. Psychological trauma is manifested when the situation cannot be addressed in such a way as to give a meaning to the event and maintain the danger under control. This may occur during a specific, sudden and intense episode, or, cumulatively, as a result of daily and constant experiences. The trauma affects the sense of self, as well as the sense that each of us gives to our existence. This semantic assignment process engages human beings for life and is different in childhood, adolescence and adulthood. The trauma can therefore be considered as a meeting between a demanding event, sometimes painful, and a mind, that has different possibilities to process it. It constitutes one of the most potent activators of emotions, and the body reacts as a sounding board. Research has amply demonstrated the physical consequences of traumatic experiences: abnormal illness behaviors (hypochondria, somatization disorders, functional syndromes), cardiovascular, metabolic or endocrine diseases, cancer and early death. In the past, in a psychoanalytic perspective, the bodily responses to trauma have been studied primarily as a symbolic expression of emotions and fantasies excluded from the mind, as in the case of hysterical conversion symptoms. Today, studies on attachment and mentalization, polyvagal theory and recent neuroscientific acquisitions have profoundly changed the understanding of the mechanisms that govern the emotion-body connection. We know that the chaotic emotional states resulting from trauma involve a dysregulation of emotions and arousal, with a somatoform dissociation which makes the individual more vulnerable to the effects of any subsequent dis-integrative trauma. The symposium will address these issues through theoretical reflections and presenting research data.

Introduction: Aim of this study is to investigate the efficacy of the NIDCAP methodology (Als, 1984), an early intervention program in a Neonatal Intensive Care Unit for reducing the risk of low psycho-motor development of the preterm born baby and difficulties in the parent-child relationship. Materials and methods: 78 families of preterm infants (gestational age

During the perinatal period affective alterations in fathers, like Paternal Perinatal Depression, are very frequent (ranging from 2% to 31%, with a mean of 10.4 %), but occur differently than in women and they are often under-assessed or undiagnosed. Depressive symptoms in fathers tend to be less severe, less definite, and often occur in comorbidity with anxiety disorders, alteration of illness behavior and behavioral acting outs like anger attacks. Moreover, in the perinatal period the mother’s and father’s emotional states are linked and empirical research has found a significant correlation between maternal and paternal depression. Some research data will be presented: 1. Fathers whose partner have suffered from affective disorders during post-partum (maternity blues or post-partum depression) show anxiety (p= .02), depressive symptoms (p= .01) and worry about their own health and paternal role up to the fifth month of pregnancy (Baldoni et al. 2014); 2. If the male is anxious, depressed or hostile during the In Vitro Fertilization and Embryo Transfer Procedure (IVF-ET), women tend to manifest more severe affective disorders, anxiety and somatization independently of the success of the procedure (Baldoni et al. not published); 3. In researches using the CARE-Index (a video recorded procedure for the study of the parent-child relationship) depression, low sensitivity and insecure attachment forerunners in fathers negatively influence the psycho-motor development of the child (p= .01) (Baldoni et al. 2012). These results suggest that anxious or depressed fathers, or those with behavioral problems, may hamper the emotional equilibrium of their companion and the development of a good mother-child relationship. In these cases, a lack of a paternal protective function as “secure base” can foster an affective disorder in the mother and negatively influence the attachment relationships and the psychosomatic development of the child.

Recent evidence-based research has shown the relationship between trauma (including neglect and sexual, physical or emotional abuse) and abnormal illness behavior. This association is more frequent in women, and the symptoms are usually neurological (chronic pain, headache), musculoskeletal (fibromyalgia), urinary-gynecological (urethral syndrome) and gastrointestinal (irritable bowel syndrome). These trauma-related problems are very common: over 30% of female patients who ask for a gastroenterological consultation were psychologically, sexually or physically abused in the past or in the present. In these cases, physiological and psychosocial factors interact in complex ways that foster the onset and duration in time of symptoms. Research has found that insecure attachment in women seems to mediate the relationship between somatization and psychological trauma. Repeated experiences of childhood abuse/neglect seem to foster a dismissing pattern (with the expectation that others will not meet one’s emotional needs) that limits the processing of the events, and promotes instead increased emphasis on, and reporting of, somatic concerns as a way to seek help from an attachment figure. This mediation is less evident in men, in which attachment and childhood traumas seem to foster somatization as independent factors. Data from a controlled study on 58 female patients from 19 to 75 years (M = 44) with functional micturition disorders (urethral syndrome) will be presented. In 65% of them, the urinary crises appeared for the first time or tended to increase in specific circumstances linked to stressful events or traumatic experiences originating from family problems (violent quarrels, separations, severe illness, death of a close relative), or from the loss of health status or social role (unemployment, retirement). In these patients, a specific inhibition of anger expression is evident (p

Depression, anxiety and abnormal illness behaviour during perinatal period: correlations between mothers and fathers Introduction During perinatal period the parent's emotional states are significantly linked and an important function of the father seems to be provision of a secure base for the mother. In fact, anxious or depressed fathers can be a handicap for the emotional equilibrium of their companion. Method To better understand the possible effects of parental affective symptoms and illness behaviour on the couple relationships and on the partner's mental state, the authors studied a sample of 50 couples assessed from the second trimester of pregnancy to the first trimester after delivery. On four occasions (at the 5th and 8th month of pregnancy, on the 3rd-6th day after delivery and at the 3rd month after delivery) all the subjects were asked to fill out the following questionnaires: the Illness Behaviour Questionnaire (IBQ), the Symptom Questionnaire (SQ), the CES-D and a Psychosocial Couple Questionnaire. Results Statistical analysis outlined that during pregnancy up to the puerperium fathers suffer from emotional alterations with oscillations that are correlated with the maternal suffering. The fathers whose partners have been diagnosed with an affective alteration during post-partum (maternity blues or post-partum depression) are more depressed (p= .01), anxious (p= .02) and show higher levels of somatization (p= .05) and hypochondria (p= .03). They tend to manifest their suffering with somatic complains (p= .001), to be less involved in the delivery and absent at the partum moment (p= .001) and to worry about their health condition and paternal role. Conclusions In our sample the partners of women who undergo depressive post-partum symptoms differ significantly from the controls and manifest more anxiety and depression, or increased affective disorders already at the fifth month of pregnancy. Psychological interventions in the affective troubles during pregnancy and puerperium would therefore concern both parents.

This is the first of three issues of the DMM News dedicated to the Adult Attachment Interview (AAI)! In these long-awaited special editions, the applications of the AAI based on the Dynamic-Maturational Model (DMM-AAI) in different fields (clinical, research, forensic) are presented by several of our AAI trainers. The three articles of this issue are centered on parents, their self-protective needs, and how knowledge about these issues may be helpful in court proceedings and treatment planning. Andrea Landini, Rebecca Carr-Hopkins and Alison Dunkerly describe the assessment of parents in family court proceedings to decide whether and how parents will be allowed to raise their children. They also highlight parental self-protective needs and resources, rather than focusing solely on parental limitations. Treatment plans are outlined in which parental self-protective needs, their influence, and sometimes interference in their relation to their children become a prominent focus. At the end of this newsletter, there is a list of upcoming 2013 DMM Courses. If – after reading – you want to learn more, you can also check The Family Relationship Institute website www.familyrelationsinstitute.org. The next training for the DMM-AAI will take place at the Tavistock Center, London (Jun. 4-9, Oct. 8-13 and Nov. 18-23, 2013). The Trainer is Andrea Landini (for information and to register contact: pmcrittenden@gmail.com).

In the perinatal period, fathers may suffer from affective disorders similar to post-partum depression with a frequency ranging in the world from 2% to 31.3%, with a mean of 10.4 % in 2010 (Paulson, Bazemore, 2010, Baldoni, Ceccarelli, 2010). The clinical expression of Paternal Perinatal Depression (PPND) differs from Maternal Perinatal Depression. In these cases the depressive symptoms are less severe, less definite, and often occur in comorbidity with other disorders whose symptoms could overlap with the affective one causing complicated clinical pictures. In particular anxious disorders, illness behaviour alteration (in particular somatically focused) and behavioural acting outs (aggressiveness, alcoholism, addiction disorders) are frequent. Moreover, in the perinatal period the mother’s and father’s emotional states are linked and empirical research has found a significant correlation between PPD and MPD. In fact, anxious or depressed fathers, or those with behavioural problems, can be a handicap for the emotional equilibrium of their companion and for the good development of the relationship between mother and child. A lack of their “secure base” protective function can foster an affective disorder in the mother and negatively influence the attachment and psychomotor development of the child. Some research data that confirm this hypothesis will be presented, in particular: 1. Fathers whose companions have undergone affective post-partum disorders show anxiety, depressive symptoms, irritability, somatic complaints and worry about their own health and paternal role up to the fifth month of pregnancy (Baldoni, Baldaro, Benassi 2009); 2. During In Vitro Fertilization and Embryo Transfer Procedure (IVF-ET), when the male is anxious, depressed or hostile, women manifest more severe affective disorders, anxiety and somatization independently of the success of the procedure (Baldoni et al. 2010); 3. Depression, low dyadic sensitivity and insecure attachment forerunners in fathers influence the development of preterm born children (Baldoni et al. 2012).

Introduction Research on families with preterm-born babies evidenced how parents with insecure attachment seem to have negative influence on the development of these children. The aim of this study is to confront precursors of attachment and parental sensitivity with the psychomotor psycho-motor development of the preterm-born child. Method 60 families with preterm-born children (2500 gr) were studied, for 180 total subjects. Mother-Child and Father-Child couples were subjected to CARE-Index (Crittenden 1979-2004), a video-recorded procedure of parent-child interaction evaluating parental sensitivity and attachment forerunners. Both parents were subjected also to Adult Attachment Interview (AAI), CES-D and STAI Y-2. The child’s psychomotor development was assessed by the Bayley Scales (BSID III). Attachment assessment followed the Dynamic-Maturational Model (DMM) criteria. Results and discussion Mothers of preterm children, compared to controls, evinced higher levels of anxiety (p

Preterm birth is a stressful and potentially traumatic event for the family. In this critical situation, the psychological characteristics of the father are important for the protection of the family and for the child development. Aim of this research was to study the influence of precursors of attachment and dyadic sensitivity of the fathers with preterm born children assessed by CARE-Index (Crittenden, 1979-2007), a video-recorded procedure of adult-child spontaneous interaction. We hypothesize that low father-infant dyadic sensitivity and the presence of precursors of insecure attachment are related to lower psychomotor development of the baby. Secondary, we hypothesize that depression and anxiety in fathers is related to a decrease in father-infant dyadic sensitivity, especially in families with preterm babies.

Paternal Perinatal Depression (PPND) refers to the onset of depressive symptoms in fathers from pregnancy to the first post-partum year (Baldoni, Ceccarelli, 2010, 2013). Although this clinical expression has been known for several decades, a specific diagnosis was suggested for the first time only a few years ago in the French psychoanalytic-oriented literature (Luca, Bydlowski, 2001). A diagnosis of PPND is preferable to that of Paternal Postpartum Depression or Paternal Postnatal Depression, since clinical onset appears to occur long before the baby’s birth, although the symptoms tend to last throughout the 12 months postpartum period. Less severe affective disorders in fathers have been described sometimes as Paternal Blues or Baby Blues. PPND differs from Couvade Syndrome which is characterized by mild somatic symptoms and typical female pregnancy behaviour that rarely develops into a worrying psychopathology. Symptoms of PPND are different from those of Maternal Perinatal Depression (MPND), even if time of onset and duration of the disease may be the same. Depressive symptoms in fathers are generally milder and less defined than in mothers and often occur in comorbidity with other syndromes whose symptoms could overlap with the affective one, or mask it, causing complicated clinical pictures.

Preterm birth is a stressful and potentially traumatic event for the family. In this critical situation, the psychological characteristics of the father are important for the protection of the family and for the child development. The paternal function is manifested not only by supporting and encouraging his partner to foster a good mother-child bond, but also directly in the relation with the child. Aim of this research was to study the influence of attachment forerunners and dyadic sensitivity of the father in the child development. A sample of 110 father-child couples, 55 with preterm born children (birth weight < 1500 g) and 55 with term born children were assessed from the first 6 months of corrected age. At 3 months of corrected age of the baby, all couples were subjected to CARE-Index, a video-recorded procedure of adult-child spontaneous interaction evaluating parental sensitivity and attachment forerunners. The child’s psychomotor development was assessed at 6 months of corrected age by the Bayley Scales of Infant Development (BSID III). Fathers of preterm children, compared to controls, showed lower dyadic sensitivity scores (p < .01) and more frequent insecure attachment forerunners (p < .01). 75% of these “preterm” fathers falls into the high risk category of the CARE-Index (requiring psychological and/or pharmacological treatment). These factors were associated with lower scores on the psychomotor development of the children at 6 months of corrected age (p < .01). The presence of insecure attachment forerunners and poor dyadic sensitivity – even in fathers with term children – seems to have a negative effect on the psychomotor development of child (p < .05). The results underlines the extreme importance of the quality of the relationship of the father with his baby from the first months of life. Poor parental sensitivity and insecure attachment forerunners influence negatively the psychomotor development of the newborn.

Aim of this research is to investigate the relation between the pattern of mothers attachment and the one of their children at 12 months of age, using the Dynamic-Maturational Method (DMM) criteria for the first time in an Italian sample. It was hypothesized that mothers with secure (or balanced) pattern (B) - more sensitive and protective towards their offspring - should foster a B pattern in their children. On the contrary, insecure mothers - less sensitive, more anxious and more controlling - should promote the development of an insecure pattern in their children. A sample of 40 Italian mothers-child dyads was initially considered and 30 mothers (aged from 19 to 40 years) and their children met criteria for inclusion in the research. A final sample of 26 dyads completed the procedures. All mothers, at the 6th month of delivery, were subjected to the Adult Attachment Interview (AAI), and afterwards to the Strange Situation (SS) when their children were 12 months old. Both procedures were administered and codified in double blind by 2 reliable codifiers following DMM criteria. Results: 23.1% of mothers resulted balanced (B), 15.4% dismissing (A), 42.3% preoccupied (C), 11.5% dismissing/preoccupied (A/C) and 7.7% in course of reorganization (R). 34.6% of children resulted secure (B), 23.1% avoiding (A), 38.5% ambivalent (C) and 3.8% avoiding/ambivalent (A/C). This study confirmed the attachment transmission hypothesis revealing a modest correlation between mother’s and child’s secure attachment (B) (p < .05). However, a reversal pattern is evinced in a significant part of the insecure sample: children of insecure mother show an opposite pattern in respect to their mother (A versus C or C versus A). This “reversal trasmission of attachment” is in line with others studies (Hautamäki el al., 2010a, 2010b; Shah, Fonagy, Strathearn, 2010) and is coherent with DMM theory.

The interest of the University of Bologna in the Dynamic-Maturational Model (DMM) began in 2000, when Patricia Crittenden was contacted regarding a longitudinal research, founded by the Italian Ministry of Education, University, and Research (MUIR) on “The development of attachment and the onset of psychological suffering in pregnancy and post-partum”. In 2001, the Attachment Assessment Lab (AAL) was founded at the Department of Psychology, and Patricia Crittenden and Andrea Landini became official partners and advisers. AAL activities includes many DMM based research, in particular on the transmission of attachment, on the attachment in families of preterm born children, and on attachment in psychotherapy. Annual conferences, seminars and training courses on the DMM are organized by the AAL, including a course from 2001 to 2005 on the administration and coding of the Adult Attachment Interview (AAI) following DMM criteria. This led to the training of the first Italian reliable coders, very active in Italian and international research. Franco Baldoni, Head of the Attachment Assessment Lab, is the International Editor and the editor of the Italian Edition of DMM News, the official journal of IASA. In 2008, at the University Centre of Bertinoro, University of Bologna, the 1st Biennial Conference of IASA was held, attended by about 200 researchers from 10 different countries. The teaching of the DMM in academic programs at the University of Bologna includes the fundamentals of the DMM, taught by Franco Baldoni in the “Clinical Methodology” course and short workshops on the CARE-Index and on DMM based AAI conducted by AAL collaborators, at the “Magistrale” degree in Clinical Psychology (a two years degree after the bachelor in Psychology). These classes are taught in Italian, but the degree course provides also some English lessons. Finally, AAL activities include internships and stages for students and mentorships for thesis and research.

Desperation is a helpless mental state that drives people to abandon their usual behavior and to seek help from others (Crittenden 1997). It represents a last attempt to protect oneself by communicating one’s state to someone else. Therefore, it reflects a final shred of hope and has adaptive value. A case study will illuminate this concept.

Objective: The aim of this study is to explore attachment forerunners and dyadic sensitivity in the family with preterm born child. Methods: 89 families, 35 with preterm born children (< 1500 gr.) and 54 with term born babies (> 2500 gr.) were studied from 3 months to 1 year corrected age (267 total subjects). Mother-child and father-child couples were subjected to CARE-Index and both parents to DAS, CES-D and STAI Y-2. The child’s psychomotor development was assessed by Bayley Scales. Results: The mothers of preterm children presented high risk interactive behaviors at CARE-Index (low scores at Dyadic Sensitivity Scale, p = .000), high anxiety (p = .003) and depression (p = .03). Preterm fathers presented low scores at Dyadic Sensitivity Scale (p = .000) and high anxiety (p = .024). In interaction, attachment forerunners suggest an insecure attachment in preterm mothers (p = .001) and fathers (p = .000) and in preterm children in the interaction with the mother (p = .028). These risk factors were correlated, in both parents, with low performance of the child at Bayley Scales (p =.04). Fathers of preterm children presented also a negative perception of the child and an unsatisfied perception of the hospital care. Conclusions: The results show in the preterm family that 40% of mothers and 75% of fathers are in high risk area suggested by CARE-Index. In these cases, insecure attachment forerunners, low dyadic sensitivity and psychological difficulties (couple conflicts, anxiety, depression) seem to influence the psychomotor development of the preterm child.

The aim of this study is to assess attachment and the role of Mother-Father-Child relationship in the family with preterm born child (< 1500 gr) from 3 months to 1 year corrected age compared with a control group of families with term-born children (> 2500 gr). 20 preterm and 20 term couples with their babies were studied (120 subjects). Mother-Child and Father-Child couples were subjected to CARE-Index and both parents to AAI, Dyadic Adjustment Scale (DAS), CES-D and STAI Y-2. The child’s psychomotor development was assessed by the Bayley Scales of Infant Development (BSID II). Attachment assessment followed the DMM criteria. Preterm mothers presented high risk interactive behaviors at CARE-Index (low scores at Dyadic Sensibility Scale, p

Human beings show an innate predisposition to develop attachment relations with primary parental figures that perform a protection function against danger. In couple and family life, this necessity is particularly evident in the perinatal period, during the adolescence and the emancipation of the offspring and in every stressful and potentially dangerous period. In these situations the family attachment system will be activated and a fundamental aspect of parenting will be to offer a secure base to the offspring, i.e. an atmosphere of safety and trust in the relationship with the attachment figure. Another parental function very important for protection from traumatic experiences is to foster mentalization. This function, a consequence of the quality of attachment, is fundamental for the development and the organization of the Self and enables regulation and control of affects and their somatic correlates, mainly in stressful circumstances. Empirical research has evidenced how in the perinatal period the mother’s and father’s emotional states are significantly linked. Moreover, in this period, fathers themselves may also suffer from affective disorders similar to post-partum depression. An important male function, in the perinatal period, seems to be provision of a secure base for his companion, helping her to overcome the difficulties, keeping suffering at endurance levels and fostering the conditions by which the special relation between the mother and the baby can develop in an adequate way. In fact, preoccupied, too anxious or depressed fathers, or those with behavioural problems (pathological aggressiveness, alcoholism, addiction disorders), can be a handicap for the emotional equilibrium of their companion and for the good development of the relationship between mother and child. Some research data confirming this hypothesis are described.

A main function of being a parent is to supply a “secure base”, i.e. a particular feeling of safety and trust in an attachment relationship. This necessity is also a characteristic of adult age and it may manifest in couple romantic love, friendship and in relation between adult offspring and parents. In couple and family life, the secure base function is particularly evident during pregnancy, in the period following the birth of a child, during the adolescence and the emancipation of the offspring and in every stressful and potentially dangerous period. An important male function, in perinatal period, seems to supply a secure base for his companion, helping her to overcome the difficulties, keeping the suffering at endurance levels and fostering the conditions by which the special relation between the mother and the baby can develop in an adequate way. In fact, preoccupied, too anxious or depressed fathers, or those with behavioural problems (pathological aggressiveness, alcoholism, addiction disorders), can be a handicap for the emotional equilibrium of their companion and for the good development of the relationship between mother and child. A lack of this protective function can foster an affective disorder in the mother and negatively influence the attachment and psychomotor development of the child.

Mentalization is the mental process by which a subject interprets, implicitly or explicitly, their and others’ behaviors as significant on the basis of intentional mental states (desires, needs, feelings, beliefs and personal motivations). The mentalization construct and the attachment theory permit new interpretation of clinical relationships. Moreover, they lead to the development of specific individual, family or group psychotherapeutic techniques for personality disorders and, more in general, for those patients that present difficulties in expression and control of emotions and impulses and more vulnerability to stress.

Aim: The purpose of this study is to assess past and present attachment relationships in outpatients affected by Inflammatory Bowel Disease (IBD) as Ulcerative Colitis and Crohn’s Disease. Methods: 664 subjects were divided in a experimental sample of 314 IBD outpatients (157 males, age from 16 to 78, m: 43.14) and a control sample of 350 non-pathological subjects, similar for sex and age, without IBD-affected relatives. In all cases the following questionnaires were submitted: 1) Parental Bonding Instrument (PBI) by Parker, et al. (1979) for the study of parental relationships in the first 16 years; 2) Attachment Style Questionnaire (ASQ) by Feeney et al.(1994) to assess some dimensions of present attachment style. The data were analyzed using Chi-square, cluster analysis and one-way Anova. Results: IBD outpatients, compared to controls, showed more frequent unsure attachment features (especially avoidant, p

Aim: Preterm birth is a dangerous and stressful event for the family, attachment behaviours will be activated and can influence the emotional and somatic development of the preterm child. The purpose of this study is to assess family attachment and child development in an experimental group of families with preterm-born children (< 1500gr) compared with a control group of families with term-born children (> 2500gr). Methods: For this report, 10 preterm and 10 term couples were studied at 3 months corrected age. Mother-Child and Father-Child couples were subjected to Child-Adult Relationship Experimental Index (CARE-Index) (Crittenden, 1979-2004) and both parents to Dyadic Adjustment Scale (DAS) (Spanier, 1976). The psycho-motor development of the child was assessed by administering the Bayley Scales of Infant Development (BSID II). Statistical elaboration was carried out using parametric and non-parametric tests (U Mann-Whitney). Results: Preterm mothers and fathers presented high risk interactive behaviours at CARE-index (low scores at Dyadic Sensibility Scale, p

Recent studies have shed light on the biological foundations of Basic Emotional Systems that can be found both in animals and in human beings. The aim of our study is to reveal the associations that exist between the Basic Emotions making up part of the personality structure, the relationship-based emotional regulatory system, i.e. Attachment Style, and the influence of these on the manifestation and expression of psychological distress. Our sample consisted of 110 subjects (M = 34, F = 76) , of whom 50 suffered from a stroke and 60 suffered from bone fractures; the average age was 72.67 (SD = 11.24). Participants were administered the following questionnaires: Feeney et al.’s Attachment Style Questionnaire (Fossati et al., 2003, Jour. Soc. Pers. Rel. 20(1), 55-79) in order to assess adult attachment styles; Zigmond and Snaith’s Hospital Anxiety and Depression Scale (Costantini et al., 1999, Support Care Cancer. 7:121–127) in order to assess the intensity of anxiety and depression; the Affective Neuroscience Personality Scales (Davis et al., 2003, Neuro-Psychoanalysis, 5(1), 57-69) in order to evaluate the Basic Emotional Systems. Notwithstanding the advanced age of the subjects, the analysis indicated the existence of a statistically significant relationship between the Attachment Style (ASQ) and the Basic Emotional Systems of the personality structure (ANPS). In particular, we found a positive correlation between Secure Attachment Style and positive emotions, while the Avoidant Attachment Style seemed to modulate only partly adaptive emotions and psychological distress (HADS).

The exposure to maltreatment and to conditions of danger during childhood and adulthood is very common among humans. In serious conditions of danger, when attachment strategies fail, adaptive defensive reactions can manifest themselves: the alternation of the expression of unsure avoidant and preoccupied patterns (A/C), as in PTSD, the desperation state, the depression state, up to the final state of learned hopelessness/helplessness (Crittenden, 1997). Desperation is a helpless mental state in which the help from others is actively researched. For this reason it preserves an adaptive value. This state can lead to a radical change in attachment strategy and promote the elaboration of traumatic experiences and the reorganization towards strategies more protective for the Self. A case of a women saved by her desperation state will be discussed. She suffered from anxiety, irritability, aggressive behaviour, endocrinal disease and was sexually abused by her father during adolescence. Using DSM-IV criteria the first diagnosis was: Anxiety Disorder associated with general medical condition (hyperthyroidism). Patient was submitted to two periods of Dynamic-Oriented Psychotherapy (one time a week). During first period, that lasted one year, a medical therapy was administered for an hyperthyroidism with exophthalmia. During the second period of psychotherapy, that lasted two years, an anti-depressive therapy was administered. Two months after the restarting of the psychotherapy attachment was assessed by AAI using DMM criteria. A few months after the second period of therapy, the physical state was normal, the psychological symptoms decreased, the spousal relationship improved and the relation with daughter and the patient’s mother improved. The attachment assessment with AAI revealed a partial Depression as a modifier, an unresolved trauma (preoccupied) for sexual abuse (no more blocked) and a A+ pattern. The configuration was: (Dp) Utr (p) sexual abuse A4-5 (7).

The aim of the research unit is to study the development of attachment, the psychological difficulties and the role of Father-Mother-Child relationship in the family with preterm birth child. We intend to study an experimental group consisting in 25 families with preterm-born children (birth weight < 1500gr) and a control group consisting in 25 families with term-born children (birth weight > 2500gr). The study is based on a longitudinal survey with gathering of data in four phases (1-3-6-12 months corrected age of the baby). The attachment assessment is conducted following the Dynamic-Maturational Model (DMM) criteria. The assessment instruments (CARE-index, Strange Situation, AAI) are administered and codified in blind conditions by expert and reliable operators trained in specific courses. The research unit will assess successively at 24 months the psycho-motor development of the child administrating the Bayley Scales of Infant Development (second edition, BSID II). At present, 10 preterm couples and 10 term couples were studied at 3 months corrected age. Preterm mothers and fathers presented high risk interactive behaviours at CARE index (low scores at Dyadic Sensibility Scale, p

Somatization is a generic and ambiguous concept widely utilized for pathological conditions where somatic symptoms are interpreted as the consequence of psychological problems or stress. It could be defined as “the transitory or persistent tendency to experiment or communicate psychological suffering as somatic symptoms and to search help for them” (Lipowski, 1988). In these patients symptoms are mainly visceral, but a lot of them also undergo psychological suffering (in particular, anxiety, depression and hypochondria) and the co-morbility with psychiatric diseases is very high. In most cases clinical or laboratory tests fail to find biological alterations that explain somatic symptoms, and the diagnosis is made by exclusion, becoming only an alibi for cultural ignorance or therapeutic inefficacy. In clinical practice, somatization is a complex problem that presents in a continuum from normal physiology to psychiatric suffering. The perception of the body activity in somatic or psychological ways depends on Illness Behaviour, i.e. “the ways in which individuals react to aspects of their own functioning which they evaluate in terms of health and illness” (Pilowsky, 1978). This disposition is highly conditioned by development, family education, cultural factors and by attachment experiences. In DMM perspective the tendency to deny or falsify negative forbidden affects (anger, fear, vulnerability, sexual excitation) is a characteristic of A configurations, especially type A+. In these cases, specific Abnormal Illness Behaviors are frequent and accompanied by somatization symptoms or functional syndromes. In some cases, the increase of emotional arousal is subjectively perceived only by its somatic aspects, the only ones that can be recognized and communicated. In this way, the subject can search help (from his attachment figure or from the doctor) for his somatic needs and not for psychological problems. In other cases, denial of the bodily signals of danger (pain, altered somatic perceptions, body function alterations) don’t permit an adequate search for psychological or medical help, resulting in the development of serious organic alterations and medical illnesses.

In the practice of clinical rehabilitation, the caregiver plays an active and participating role in the patient’s mental processes. Moreover, the attachment style of the caregiver is associated with a particular type of care (Feeney, 1996). Caregivers with a secure style tend to be empathic and to actively offer assistance, while those with an insecure style exhibit different types of non-responsive caregiving, depending on their particular type of insecurity. We hypothesise that subjects with a secure attachment style will exhibit lower levels of psychological distress and higher levels of functional independence compared to those with an insecure style. We further expect that a relationship between patient and caregiver characterised by secure attachment strategies will be correlated with a more positive outcome of recovery compared to relationships based on an insecure style. Finally, differences may be found between patients with lesions of the right hemisphere, those with lesions of the left hemisphere and orthopaedic patients. Description of the sample: The study excludes patients with severe cognitive deficits. The sample consists of 35 stroke patients (M = 66%, F = 34%; average age = 69 with SD = 9.7; married = 66%) and 30 patients with fractures (M = 27%, F = 73%; average age = 75 with SD = 9.3; married = 50%), as well as the patients’ caregivers. In the neurological patients, the cerebral lesion is located in the right hemisphere in 60% of the cases, while most of the strokes are ischaemic in nature (66%). A share of 70% of the patients with right-hemisphere lesions exhibits modifications in cognitive functioning (neglect: 38%). Among the patients with lesions of the left hemisphere, around 60% show alterations in the cognitive profile (aphasia: 43%). A share of 50% of the orthopaedic patients (74% of the cases with femoral fractures) exhibits modifications of the cognitive profile. The caregivers of the post-stroke patients (spouse: 43%, son or daughter: 46%) are more frequently women (57%) with an average age of 53; 74% are married. Men and women are equally represented among the caregivers of the orthopaedic patients (spouse: 47%, son or daughter 50%); these caregivers have an average age of 61, and 80% are married. Tools and methodology: The HAD (Hospital Anxiety and Depression scale by Zigmond and Snaith, 1983), with separate subscales for anxiety and depression, was used to assess the psychological distress of the patients on admission and on discharge. The patients’ level of functional independence was also tested on admission and discharge by means of the FIM scale (Functional Independence Measurement, by Dodds et al., 1993). The CES-D scale (Center of Epidemiologic Studies Depression scale, by Radloff, 1977 in the Italian form validated by Fava, 1982) was used to measure the presence and degree of depression in the caregivers, likewise on admission and discharge. The attachment style of both patients and caregivers was identified using RQ (Relationship Questionnaire by Bartholomew and Horowitz, 1991) and ASQ (Attachment Style Questionnaire by Feeney, 1996 in the Italian version validated by Fossati et al., 2003). The ASQ evaluates attachment style according to five key factors: “confidence discomfort with closeness”, “need for approval”, preoccupation with relationships” and “relationships as secondary”. The preliminary findings appear to confirm most of the hypotheses formulated above.

Major hypotheses: 1) Preterm birth is a dangerous and stressful event for the family. The parental Internal Working Models and couple attachment will be activated with defensive and adaptive behaviours that can influence the family relationships and the development of preterm child attachment. 2) During perinatal period the emotive states of mothers and fathers are connected. 3) The psychological characteristics of the father are important for the protection of the family and the development of secure attachment in the child. Assessment: - Sample: couples with preterm birth children (≤1500 gr.) and couple with term birth children (≥2500 gr.) studied from 3 months to 1 year corrected age. - Methods: At 3 months corrected age: Mother-Child and Father-Child: • Child-Adult Relationship Experimental Index (CARE-Index) (Crittenden 1979-2004) Parents: • Adult Attachment Interview (AAI) (George , Kaplan, Main 1986; Crittenden 1999) • Center for Epidemiologic Studies Depression Scale (CES-D) (Radloff 1977) for evaluation of depressive symptoms • Dyadic Adjustment Scale (DAS) (Spanier 1976) for evaluation of couple adaptation and partner representations • State Trait Anxiety Inventory Y2 (STAI-Y2) (Spielberger et al. 1983) for evaluation of trait anxiety At 1 year corrected age: Mother-child: • Strange Situation (SS) (Ainsworth, Witting 1969) Status of the research: 10 preterm couples and 10 term couples were studied at 3 months corrected age. Preterm mothers and fathers presented high risk interactive behaviours at CARE index (low scores at Dyadic Sensibility Scale, p

In this study was used for the first time the Attachment Movie Test (AMT), a new instrument to evaluate specific dimensions of attachment. This test uses various filmed scenes that put the subject in a condition of moderate stress. In this way the Internal Working Models relative to attachment (as unconscious cognitive schemes evidentiated by conditions of insecurity) are better evaluated. AMT has proven to be particularly suitable for adolescents and young adults. Authors hypothesized that: - adolescents who are residents in re-educational communities (Experimental Group) show a significantly higher rate of insecure attachment when compared to other adolescents who live in their families (Control Group). - AMT correlates with other attachment tests and evaluates some specific dimensions of adolescent attachment.