A influência do estilo de apego na clínica e no tratamento de mulheres com Transtorno de Estresse Pós Traumático após violência sexual
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Data
2024-05-03
Autores
Maciel, Mariana Rangel [UNIFESP]
Orientadores
Mello, Andrea de Abreu Feijó de [UNIFESP]
Tipo
Tese de doutorado
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Introdução: Estilos inseguros de apego estão estabelecidos como fator de risco para desenvolvimento de Transtorno de Estresse Pós-Traumático (TEPT) e como preditores de evolução e resposta ao tratamento do quadro. Estilo de apego no adulto pode mudar a depender das experiências ao longo da vida e com o próprio tratamento. Objetivos: Procuramos investigar as dimensões de apego em mulheres adultas com TEPT após violência sexual, tratadas por 14 semanas com psicoterapia interpessoal ou medicação sertralina. Investigamos se houve mudança nas dimensões de ansiedade e evitação do apego ao longo do tempo; avaliamos se estas mudanças nas dimensões de apego foram mediadoras da resposta ao tratamento; e verificamos se a resposta ao tratamento esteve associada com as dimensões de ansiedade e evitação de apego. Métodos: Um grupo de 74 mulheres foi acompanhado por 14 semanas. Foram aplicadas a Escala de TEPT Administrada pelo Clínico-5 (CAPS-5) e a Escala Revisada de Apego no Adulto (RAAS) no início do estudo, na semana 8 e na semana 14 de tratamento. Realizamos um modelo paralelo de mediação para explorar se havia papel mediador de mudança no apego na redução dos sintomas do TEPT causada pelos dois tratamentos realizados, ou seja, efeito indireto via dimensões de evitação e ansiedade. Modelo linear múltiplo foi desenvolvido para explicar os valores das dimensões de apego no início do estudo. Dois modelos lineares mistos foram estruturados para verificar como cada uma das duas dimensões de apego variou ao longo do tempo de seguimento (desfecho RAAS), e como os sintomas de TEPT variaram ao longo das 14 semanas de acompanhamento em função das dimensões de apego e de outras variáveis relevantes (desfecho CAPS-5). Resultados: O modelo de mediação não evidenciou efeito indireto das intervenções nos sintomas de TEPT via dimensões de apego. Observamos no início do estudo relação de maior ansiedade do apego com experiências adversas na infância e adolescência; nenhuma variável relacionou-se com a dimensão evitação. A dimensão ansiedade do apego não mudou ao longo do tratamento. Já a dimensão evitação do apego apresentou aumento ao longo das 14 semanas, maior para as pacientes com mais sintomas de TEPT, de origem étnica não-branca (negras, pardas e asiática), e mais jovens. Analisando o desfecho dos sintomas de TEPT ao longo do tempo, observamos interação significativa e negativa com o tempo – redução dos sintomas de TEPT em relação ao início do estudo. A redução dos sintomas de TEPT foi quase 5 pontos maior nas mulheres negras, pardas ou asiáticas. Houve associação entre os sintomas de TEPT e apego; quanto maior o escore de ansiedade, maior o nível de sintomas de TEPT. Essa relação teve interação estatisticamente significante com tempo: valores maiores da CAPS são encontrados à medida que o escore de ansiedade do apego fica mais alto. Conclusão: As dimensões de apego apresentaram comportamento diferente do esperado, com aumento do nível de evitação ao longo do tratamento, apesar da redução dos sintomas de TEPT; este aumento foi maior nas mulheres que se mantiveram mais sintomáticas do TEPT. Maior ansiedade do apego esteve associada com pior resposta ao tratamento do TEPT.
Introduction: Insecure attachment styles have been established as risk factors for the development of posttraumatic stress disorder (PTSD). Insecure attachment has also been implicated in the prognosis of PTSD and other psychiatric disorders, as well as in treatment response. Adult attachment may change after extreme experiences throughout the lifetime and through mental health treatment. We analyzed attachment dimensions in women with acute PTSD following sexual assault, who were enrolled in a clinical trial for the treatment of the disorder with the medication sertraline or Interpersonal Psychotherapy. Objectives: To investigate if attachment dimensions of anxiety and avoidance changed across follow up; if changes in attachment mediated treatment response; and if treatment response was influenced by attachment dimensions scores. Methods: A total of 74 adult women were followed for 14 weeks. They answered the Revised Adult Attachment Scale (RAAS) at baseline, week 8, and week 14. PTSD symptoms were evaluated at the same timepoints using the ClinicianAdministered PTSD Scale 5 (CAPS5). We performed a parallel mediation model to explore indirect effects via attachment avoidance and anxiety dimensions in the change of PTSD symptoms. We fitted a generalized linear model to explain the attachment anxiety and avoidance scores at baseline. We developed a linear mixed model to investigate how attachment dimensions changed over time. Lastly, to understand how PTSD symptoms varied across treatment according to attachment status, we performed a linear mixed model with CAPS5 scores as the outcome. Results: We did not find an indirect effect via attachment dimensions in the PTSD symptoms across the study. At baseline, attachment anxiety was associated with a history of early trauma, and no variables were significantly related to attachment avoidance. Attachment anxiety remained stable during the followup. Attachment avoidance, on the other hand, significantly increased from baseline to week 14. Higher avoidance scores were observed in patients with higher total PTSD scores, and in Black, mixedrace, or Asian women. Older age was associated with decreased avoidance. In our analysis of PTSD symptoms, there was a negative relation with time in both groups. The reduction was almost 5 points greater for patients that were Black/mixedrace/ Asian. Regarding attachment, CAPS5 scores remained greater for patients with higher levels of attachment anxiety, and this relationship significantly interacted with time – higher CAPS5 scores were found as attachment anxiety became higher. Conclusion: Attachment dimensions displayed different behavior than expected. Contrary to our expectations, we observed an increase in attachment avoidance across followup, despite reduction in PTSD symptoms. The increase was greater for women who remained more symptomatic, suggesting a treatmentresistant profile. Higher attachment anxiety was associated with inferior treatment response.
Introduction: Insecure attachment styles have been established as risk factors for the development of posttraumatic stress disorder (PTSD). Insecure attachment has also been implicated in the prognosis of PTSD and other psychiatric disorders, as well as in treatment response. Adult attachment may change after extreme experiences throughout the lifetime and through mental health treatment. We analyzed attachment dimensions in women with acute PTSD following sexual assault, who were enrolled in a clinical trial for the treatment of the disorder with the medication sertraline or Interpersonal Psychotherapy. Objectives: To investigate if attachment dimensions of anxiety and avoidance changed across follow up; if changes in attachment mediated treatment response; and if treatment response was influenced by attachment dimensions scores. Methods: A total of 74 adult women were followed for 14 weeks. They answered the Revised Adult Attachment Scale (RAAS) at baseline, week 8, and week 14. PTSD symptoms were evaluated at the same timepoints using the ClinicianAdministered PTSD Scale 5 (CAPS5). We performed a parallel mediation model to explore indirect effects via attachment avoidance and anxiety dimensions in the change of PTSD symptoms. We fitted a generalized linear model to explain the attachment anxiety and avoidance scores at baseline. We developed a linear mixed model to investigate how attachment dimensions changed over time. Lastly, to understand how PTSD symptoms varied across treatment according to attachment status, we performed a linear mixed model with CAPS5 scores as the outcome. Results: We did not find an indirect effect via attachment dimensions in the PTSD symptoms across the study. At baseline, attachment anxiety was associated with a history of early trauma, and no variables were significantly related to attachment avoidance. Attachment anxiety remained stable during the followup. Attachment avoidance, on the other hand, significantly increased from baseline to week 14. Higher avoidance scores were observed in patients with higher total PTSD scores, and in Black, mixedrace, or Asian women. Older age was associated with decreased avoidance. In our analysis of PTSD symptoms, there was a negative relation with time in both groups. The reduction was almost 5 points greater for patients that were Black/mixedrace/ Asian. Regarding attachment, CAPS5 scores remained greater for patients with higher levels of attachment anxiety, and this relationship significantly interacted with time – higher CAPS5 scores were found as attachment anxiety became higher. Conclusion: Attachment dimensions displayed different behavior than expected. Contrary to our expectations, we observed an increase in attachment avoidance across followup, despite reduction in PTSD symptoms. The increase was greater for women who remained more symptomatic, suggesting a treatmentresistant profile. Higher attachment anxiety was associated with inferior treatment response.
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Citação
Maciel, Mariana Rangel. A influência do estilo de apego na clínica e no tratamento de mulheres com Transtorno de Estresse Pós Traumático após violência sexual . 2024. 163 f. Tese (Doutorado em Psiquiatria e Psicologia Médica) - Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, 2024.