Thérapie Intégrée d’Attachement pour le trouble dépressif persistant : une étude pilote

Abstract

Persistent depressive disorder (PDD), newly developed in DSM-5, merges the diagnoses of chronic major depressive disorder with that of dysthymia. In comparison with the characterized depressive episode, PDD is distinguished by a more marked negative impact on the quality of life, a greater risk of hospitalization and suicide attempts, an often-earlier onset, and a duration of several years to several decades. The treatment of PDD is faced with a high rate of treatment failure or partial remission. In terms of psychotherapy, the only specific psychotherapy adapted to chronic depression is the Cognitive-Behavioral Analysis System of Psychotherapy (CBASP). The initial trial showed that it had effects comparable to those of antidepressants and significantly increased efficacy when combined with medication. Subsequent trials, however, showed mixed results. Until now, PDD does not seem to answer to any know validated therapy for depression. One of the hypotheses that can explain this lack of results is attachment insecurity. Indeed, attachment insecurity is increasingly tackled in literature without being taken into consideration in conventional therapies. Although depression is multifactorial in origin, we now know that insecure attachment is a major risk factor for developing depression. In previous studies, insecure attachment is significantly associated with long-term depression. Considering this, the Attachment Integrated Therapy was adapted for PDD from an attachment-based approach. We felt it was essential to integrate the attachmental dimension in this conception since we raise relational problems, especially those that originate in early relationships. AIT is a time-limited therapy that was developed to support clients with insecure attachment whose security requires a direct and profound restructuring of attachment. AIT focuses mainly on what underlies the activation of the attachment system (in the event of threats to the relationship with the attachment figure), namely the representations of the self and of others by working on the concepts of self-confidence and confidence in others and their link with self-esteem. Secondarily, by enabling the patient to develop attachment interaction skills. To achieve these two objectives, the AIT was developed in line with Bowlby's recommendations. Although Bowlby did not develop a therapy founded on his theory, he nevertheless identified five therapeutic tasks that can guide the attachment-oriented therapist in shaping their work. The purpose of the study was to assess the results of AIT on PDD, found at the beginning (T1) at end of therapy (T2), and one year after therapy (T3) on three levels: depressive symptoms, attachment insecurity and social support. This study included eleven clients, suffering from PDD followed in an outpatient setting, at the Sainte-Anne hospital in Paris. The assessments were conducted on three levels: Depressive symptomatology (MINI, BDI-II), Attachment (RSQ) and Social Support (SSQ6). The BDI-II- results over the three assessment times show an evolution, with an average reduction of depressive scores of 50% between the beginning and the end of the therapy. In addition, attachment insecurity as reflected in attachment styles as well as representations of self and others also improves with the AIT. The results at T3 shows the AIT is still helpful with the depressive symptoms, the self-representations, and the social support 1 year after the therapy completion even if we found an increase in the depressive symptoms at T3. However this increase, not being statistically significant, we can conclude that AIT still works 1 year after without speaking of relapse. Concerning the representation of self, we found an increase in the scores between T1 et T2 and a stabilization between T2 and T3. This shows that AIT continues to have an effect on the image of self, one year after therapy. However this improvement is not found in the representation of others, we found an improve between T1 and T2 even if it was not significant. However, the scores decrease between T2 and T3. Concerning the last variables, we noticed an improvement in the availability perceived by the participants between T1 and T3 with an improvement of the average mean. Regarding satisfaction, we also notice a significant improvement in T3. The findings and outcomes of the outpatient AIT program are promising. Moreover, this study suggests that chronic activation of the attachment system may be a predictor of the development of depressive persistent disorder. When treating depressive persistent disorder, attachment should therefore be addressed.