Journal of Affective Disorders 210 (2017) 130–138

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Journal of Affective Disorders

journal homepage: www.elsevier.com/locate/jad

Research paper

Attachment representations, patterns of emotion regulation, and social MARK

exclusion in patients with chronic and episodic depression and healthy
controls
⁎
C. Bauriedl-Schmidta, ,1, A. Jobsta,1, M. Ganderb, E. Seidla, L. Sabaßa, N. Sarubina,c, C. Mauera,
F. Padberga,1, A. Buchheimb,1
a
Department of Psychiatry und Psychotherapy, Ludwig-Maximilians-University, Munich, Germany
b
Department of Psychology, Clinical Psychology, University of Innsbruck, Austria
c
Hochschule Fresenius, University of Applied Sciences, Munich, Germany

A R T I C L E I N F O A BS T RAC T

Keywords: Background: The experience of social exclusion (ostracism) is linked to the etiology and maintenance of
Attachment representation depression. Most individuals experience emotional stress in states of social exclusion. Insecurely attached
Chronic depression individuals, especially with an unresolved trauma, show maladaptive coping in response to social stress. The
Episodic depression present study examines (a) the differences with regards to attachment representations in episodic (ED) and
Emotion regulation
chronic depressive (CD) inpatients and (b) how ostracism affects their emotional reactions.
Ostracism
Social exclusion
Methods: Patients with CD (n=29) and ED (n=23) and healthy control subjects (n=29) were interviewed using
the Adult Attachment Projective Picture System (AAP), a valid measure to assess attachment representation;
and played a virtual ball tossing game simulating social exclusion (Cyberball). Multiple depression-related risk
and protective factors were considered. We hypothesized that CD patients show the most severe attachment
disorganization and are emotionally most affected by the social exclusion situation. Moreover, we explored the
interaction between ostracism and attachment.
Results: Contradicting our hypotheses, ED and CD individuals were almost akin with regards to their
attachment insecurity/disorganization and reactions to Cyberball. An emotionally altered reaction to social
exclusion was identified in the insecure-disorganized depressive subgroup.
Limitations: Small sample size hampering further subgroup analyses. The ED sample may include single CD
subjects with recent manifestation.
Conclusions: The pattern of emotion regulation in the depressive groups matches with findings from clinical
studies, including attachment research. The relationship between attachment representations and ostracism
should be further investigated in larger samples of depressive individuals.

1. Introduction
The experience of loss, social exclusion (ostracism) and rejection is
linked to the etiology and maintenance of depression from different
clinical perspectives (Bowlby, 1969; Coyne, 1976; McCullough, 2003;
Allen and Badcock, 2003; Eisenberger, 2012; overview: Buchheim
et al., 2012, 2013). The fifth version of the DSM (APA, 2013)
acknowledges that episodic (ED) and chronic (CD) depression seems
to be fundamentally different diseases (Klein et al., 2006; Moeller et al.,
2014). Studies show that CD in comparison to ED is the more severe
form (Angst et al., 2009; Jonsson et al., 2011; Brockmeyer et al., 2015;
Koehler et al., 2015) as chronic depressive patients have more and
longer hospital stays (e.g. Schramm et al., 2011; Brockmeyer et al.,
2015; Koehler et al., 2015). The onset of CD is earlier and more CD
patients report an early onset before the age of 21 (Klein et al., 2014;
McCullough, 2003), which is associated with more severe impairment
(Berndt et al., 2000), a more aversive progression (Klein et al., 1999;
Brockmeyer et al., 2015), as well as more relapses (Agosti, 1999) than a
late start. Persistent depression increases the vulnerability in adoles-
cence to social, psychological, somatic and other psychiatric problems
(Klein et al., 2004; Jonsson et al., 2011; Schramm et al., 2011).
Individuals with CD report earlier childhood trauma (Lizardi et al.,

⁎
Corresponding author.
E-mail address: christine@bauriedl-schmidt.de (C. Bauriedl-Schmidt).
1
These authors contributed equally to this work.

http://dx.doi.org/10.1016/j.jad.2016.12.030
Received 1 May 2016; Received in revised form 29 September 2016; Accepted 17 December 2016
Available online 21 December 2016
0165-0327/ © 2016 Elsevier B.V. All rights reserved.
C. Bauriedl-Schmidt et al.
1995; Wiersma et al., 2009), more interpersonal problems (Schramm
et al., 2011), and emotional as well as cognitive-behavioral avoidance
(Brockmeyer et al., 2015).
Since there is a relatively high amount of the documented therapy
resistance in (chronic) depression the disorder is a big challenge for the
health system worldwide (e.g. Kornstein and Schneider, 2001; Trivedi
and Daly, 2008; Holtzheimer and Mayberg, 2011; WHO, 2012).
Therefore specific therapeutic approaches are requested that consider
the individual mechanism underlying ED and CD to enhance efficacy
(e.g. McCullough, 2003; Holtzheimer and Mayberg, 2011; Jobst et al.,
2016). A large recent review on psychotherapy in chronic depression
provides a meta-analysis of the present literature and recommenda-
tions for evidence-based treatments (Jobst et al., 2016). One of the
highly recommended treatments is CBASP (Cognitive Behavioral
Analysis System of Psychotherapy, McCullough, 2000) based on the
assumption that early attachment and interpersonal trauma has
resulted in dysfunctional mechanisms of derailed affective and motiva-
tional regulation and a reduction of perceived functionality.
Affective disorders in general are associated with the predominance
of insecure attachment representations (Bakermans-Kranenburg and
van IJzendoorn, 2009; West and George, 2002). Moreover, recent
research points at the particular relevance that the disorganized
unresolved attachment pattern has for the CD (Buchheim and
George, 2012). In this group unresolved trauma is mostly associated
with experiences of loss of or rejection by a significant other (Bowlby,
1980; Buchheim et al., 2013). Bowlby (1969) conceptualized attach-
ment as an evolutionarily developed biological-behavioral human
system. The individual develops internalized mental representations
of attachment and attachment figures in early infant-caregiver inter-
actions. These may adapt to continuing experiences gained throughout
the life span, but are nonetheless relatively stable (Bowlby, 1980) and
generalized across various relationship-types, such as with parents or
romantic partners (Waters et al., 2015). Secure attachment is char-
acterized by integrated representations of self and others, and is
considered to be a protective factor against mental illness (Bowlby,
1980; Fonagy et al., 1996; West and George, 2002; Ward et al., 2006;
Bakermans-Kranenburg and van IJzendoorn, 2009; Buchheim and
George, 2011, 2012). If individuals experience incomplete or compro-
mised parental protection, they develop internal working models that
may contain defensive processes (“deactivation” or “cognitive discon-
nection”) to exclude the overwhelming experience and to organize
difficult emotions (George and Solomon, 2008; George and West,
2012). When the attachment figure is entirely unavailable, e.g. through
loss, or is highly neglectful, abusive or showing failed protection, the
individual makes use of a third, more extreme defensive process that
Bowlby termed “segregated systems” (Bowlby, 1980). This process is
linked to disorganized representations also called “unresolved trauma”
(Main, 1995; George et al., 1999). Especially disorganized defensive
processes turn out to be maladaptive later in life (George and West,
2012; Buchheim and George, 2012). These maladaptive processes are
the basis for impaired affect regulation and a low level of interpersonal
functioning (Diamond et al., 2014; Browne and Winkelman, 2007), as
well they are related to impaired capacity to mentalize one's own or
other's states of mind in attachment relevant contexts (Fonagy et al.,
1998), and are risk factors for psychiatric illnesses (Buchheim and
George, 2011; George et al., 1999).
Another factor underlying the development of depressive symptoms
are experiences of social exclusion (Allen and Badcock, 2003). Williams
(2009) proposes an evolutionarily grown “ostracism detection system”
that senses even tiny markers of social exclusion. A lot of research
proves the assumption, that ostracism threatens four fundamental
human needs to belong, to self-esteem, to control and to meaningful
existence and thus deprives the individual from the satisfaction of
needs that are relevant for the motivation, survival, efficacy (overview:
Williams et al., 2000). According to the temporal need-threat-model
the reactions to social exclusion are separated in three phases
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Journal of Affective Disorders 210 (2017) 130–138
(Williams, 2009). An immediate trans-individual reflexive impairment
of mood can be differentiated from individually reflected coping, such
as the fight, flight, and socialize responses. Prolonged exclusion may
lead to resignation and depression. The virtual computer game
“Cyberball” is a well-studied and described paradigm to efficiently
and reliably induce and investigate the influence of social exclusion
under standardized conditions on affective reactions and behavioral
choices (Williams, 2009; Hartgerink et al., 2015), regardless of
individual characteristics (Zadro et al., 2004, for groups with psychia-
tric diagnoses: Staebler et al., 2011; Jobst et al., 2014, 2015). To our
knowledge, only one other research group has investigated the effects
of ostracism on groups of depressive individuals and identified
heightened activity in the ”social pain” brain area during the
Cyberball game as a predictive marker for increased depressive
symptoms one year later (Masten et al., 2011).
In this study, psycho-behavioral indicators for the “attachment” and
the “ostracism detection” system were investigated in two groups of
comparably severely affected inpatients with CD and ED compared to a
healthy control (HC) group. On the basis of previous studies, we
hypothesized that chronic depressive (CD) individuals would report (1)
more childhood trauma and would show (2) a higher amount of
unresolved trauma in their attachment representations than episodic
depressive (ED) individuals. (3) In the social exclusion paradigm, an
impaired reaction pattern would be more prominent in CD subjects
compared to the ED and HC groups, i.e. they would have more
indicators of emotion dysregulation (e.g. negative mood, need threat),
and choose more passive behaviors, than ED subjects. (4) On an
explorative level, we were interested to investigate in the attachment
related subgroups of both depression groups the differences in the
reactions to the Cyberball paradigm.
2. Method
2.1. Study population and procedure
A total of 81 individuals (42 male) between 18 and 75 years were
included. The groups of CD (n=29) and ED (n=23) were inpatients of a
German psychiatric university hospital. Inclusion criteria for ED were
single or recurrent depressive episodes lasting less than 2 years, both
with inter-episode full recovery. Key inclusion criterion for CD was a
DSM-IV diagnoses (APA, 1994, German version: Saß et al., 1998) of (1)
major depressive disorder (MD), (2) recurrent MD with no full inter-
episode recovery, (3) dysthymic disorder, or (4) MD superimposed on a
dysthymic disorder (double depression) lasting at least 2 years.
Individuals with a history of psychosis, bipolar disorder, acute addic-
tion, suicidal state, severe organic disease, or current pregnancy, were
excluded.
Healthy controls (HC) (n=29) were recruited via announcements
and were matched in age, gender, education and marital status (see
Table 1) with the two depression groups. A semi-structured telephone
interview included the screening questions of SCID-I (German version:
Wittchen et al., 1997) supplemented by questions referring to affective
disorders, psychosis and organic diseases. Moreover the Beck
Depression Inventory (BDI-II, German version: Hautzinger et al.,
2006) was administered (inclusion score: 10 maximum). Our included
participants met the general criteria, never developed addiction (life-
time), and had no psychotherapy or severe organic disease within the
last ten years. Persisting organic diseases should be under medicinal
control. Only n=1 participant showed an accentuation of personality
features (high score in SCID-II, German version: Wittchen et al., 1997).
Moreover instruments assessing the degree of functioning were
administered (Fig. 1) to all participants: Severity of symptoms was
ascertained by using validated clinical instruments: The Hamilton
Rating Scale for Depression (HDRS, Hamilton, 1960), and BDI-II.
Resilience was determined by using the commonly used Connor-
Davidson-Resilience Scale (CD-RISC, 25 Items, Connor and
C. Bauriedl-Schmidt et al. Journal of Affective Disorders 210 (2017) 130–138

Table 1
(a) Sample characteristics (socio-demographic, clinical) and (b) early childhood trauma (CTQ).

A Characteristics CD ED HC

n (%) n (%) n (%) Comparisons

Gender: male 17 (58.6) 10 (43.5) 15 (51,7) Pearson χ2=1.178, df=2, p=.555

Married/partnership 12 (44.4) 9 (39.2) 6 (20.7) Pearson χ2=.988, df=6, p=.610
Educational status: A-level 19 (65.5) 10 (43.5) 16 (55.2) Kruskal-Wallis-Test: χ2=1.774, df=2, p=.412
Comorbid Personality Accentuation Cluster C 10 (37.0) 8 (38.1) Exact Fisher Test (1-sided exact significance): .500
Early Onset 12 (41.4) 5 (21.7) Pearson χ2=2.249, df=1, p=.076
Amount of prior episodes: 1–2 8 (27.6) 14 (60.8) Z-test with Bonferroni-correction: p < .05
Amount of prior episodes: No information possible 5 (17.2) 0 Mean (SD) episodes in ED: 2.8 (2.2)
Mean (SD) Mean (SD) Mean (SD)

Age (years) 46.7 (14.2) 43.1 (11.5) 46.3 (13.6) ANOVA: F2,78=.545, p=.582
Hospitalization due to depression, lifetime (weeks) 82.0 (82.7) 82.3 (33.9) U(nCD=26,nED=22)=251.000, p=.235
Psychotropic medication (amount) 2.9 (1.0) 2.7 (1.0) T=−.831, df=49, p=.205
Amount of Axis I or II Diagnosis 1.1 (1.2) 1.1 (1.7) U(nCD=27,nED=21)=248.000, p=.215
Depression severity (HRSD) 22.3 (9.7) 23.8 (9.5) U(nCD=29,nED=23)=303.000, p=.287
Depression severity (BDI-II) 26.9 (9.7) 26.6 (10.8) T=−.089, df=50, p=.465

Resilience (CD-RISC) 48.5 (20.3) 44.3 (17.1) 71.7 (13.8) ANOVA: F2,72=19.994, p=.000**

CD vs. ED post hoc: 4.231, p=.500b

B CTQ Mean (SD) Mean (SD) Mean (SD) Statistic1 p-value

Emotional Abuse 10.6 (5.0) 12.0 (5.0) 6.2 (1.5) 26.2822 .000**
274.5003 .138
162.0004 .000****a
86.5005 .000****a

Physical Abuse 7.0 (3.7) 9.0 (5.5) 5.5 (1.1) 11,4742 .003**
263.5003 .088
293.0004 .012***a
171.0005 .001****a

Sexual Abuse 6.1 (2.4) 6.0 (2.8) 4.9 (.7) 7.7852 .020*
323.0003 .793
309.5004 .001****a
253.5005 010***a

Emotional Neglect 12.7 (5.2) 13.8 (3.6) 8.9 (3.7) 17.4642 .000**
277.5003 .150
238.5004 .002****a
110.0005 .000****a

Physical Neglect 7.4 (3.2) 9.2 (3.5) 6.3 (1.7) 11.1372 .004**
223.5003 .020***a
331.5004 .075
160.0005 .001****a

Note: CD = chronic depression, ED = episodic depression, HC = healthy control, SD = Standard Deviation, HRSD: Hamilton Rating Scale for Depression, BDI: Beck Depression
Inventory, CD-RISC = Connor-Davidson Resilience Scale, 1 = Statistics refer to overall groups comparison (1. value) and to comparison of CD vs. ED (2. value), 2 = Kruskall-Wallis-Test,
df=2, 3 = Mann-Whitney-U-Test, nCD=29, nED=23, 4 = Mann-Whitney-U-Test, nCD=29, nGK=29, 5 = Mann-Whitney-U-Test, nED=23, nGK=29, *= 2-sided (asymptotic) significance
according to level of significance set at α=.05, **= 2-sided (asymptotic) significance according to level of significance set at α=.01, ***= 1-sided (asymptotic) significance level set at
α=.05, ****= 1-sided (asymptotic) significance according to level of significance set at α=.01, SD = Standard Deviation, a = Bonferroni-Holm-correction, three comparisons, b =
Bonferroni post hoc

Fig. 1. : Procedure of Investigation Annotation: This investigation was part of a larger study and included more measures than displayed here. Therefore it took 3–5 sessions as well as
homework to complete the whole procedure.

132
C. Bauriedl-Schmidt et al.
Davidson, 2003). Traumatic experiences in the past were assessed with
the Childhood Trauma Questionnaire (CTQ, 28 items, Bernstein and
Fink, 1998).
Socio-demographic, basic clinical characteristics of the diagnostic
subgroups and the respective test statistics are described in Table 1:
The depressive subgroups did not significantly differ in terms of early
or late onset of depression, duration of hospitalization lifetime,
comorbidity with DSM-IV Axis 1 and/or 2 diagnosis, and amount of
psychotropic medication. Both depressive subgroups showed present
moderate depression and a comparable low resilience score (CD-RISC)
(Table 1). A significant difference was found in the frequency distribu-
tions of prior depressive episodes (Pearson χ2=8.946, df=4, p=.031).
More ED than CD patients reported only a few, i.e. one or two prior
episodes. Anyhow, on average, the ED patients reported three former
episodes.
40.7% of the CD and 57.1% ED patients presented no comorbidity
with another psychiatric diagnosis. Almost 40% of the CD and ED
participants showed comorbidity with a Cluster C personality disorder,
that is avoidant, dependent, and obsessive-compulsive disorders. The
latter is consistent with previous research (Buchheim et al., 2012,
2013; Kornstein and Schneider, 2001).
The depressive groups were treated with an average amount of
three types of psycho-pharmaceuticals: antidepressants, second-gen-
eration antipsychotics, mood stabilizers and/or benzodiazepines.
82.1% of the CD (82.6% ED) individuals reported intake of additional
remedies (predominantly internistical) compared to 37.9% of the HC
(Table 1, A).
This study was approved by the local ethics committee of the
Medical Faculty of the Ludwig-Maximilians-University, Munich,
Germany. All participants gave their written informed consent.
2.2. Adult Attachment Projective Picture System (AAP)
The Adult Attachment Projective Picture System (AAP, George
et al., 1999) is a semi-structured attachment interview designed to
assess adult attachment representations. The AAP procedure begins
with a neutral picture followed by seven attachment-activating draw-
ings of scenes depicting solitude, separation, illness, death, and
maltreatment. The individuals are asked to tell stories about each
picture using three standardized questions (e.g. What are the char-
acters thinking or feeling? ) Trained psychologist/ psychiatrist admi-
nistered the interview procedure. Based on verbatim transcripts, each
stimulus is coded for content and defense according to the AAP
guidelines (George and West, 2011). On the content level, coders
evaluate in the stories (a) the capacity for attachment relationships to
foster productive action (agency of self) and (b) the reported desire to
be in relationships with others (connectedness) for pictures presenting
characters alone as well as or for pictures portraying characters in
dyads: (c) synchrony, i.e. the balance and mutuality in attachment
relationships. These dimensions are rated on 3-point ordinal scales:
integrated, functional, no capacity. First, integrated agency of self e.g.
refers to themes of thoughtful self-exploration, whereas functional
agency refers to functional problem-solving behavior. Second, indivi-
duals with an integrated connectedness show a propensity to establish
intimate relationships (i.e. attachment-caregiving figure), whereas
those with a functional connectedness rather demonstrate the desire
to be with other people more generally (e.g. teacher, doctor). Third, an
integrated form of synchrony is reflected in the characters’ reciprocal
interactions and mutual enjoyments, whereas in those with functional
synchrony, this does not seem to be desirable for the characters.
For all picture stimuli, the AAP coding finally distinguishes between
three forms of defense: Deactivation is used to move attention away
from attachment-related stressors by reducing the need for attachment
relationships as important (e.g. neutralization). Cognitive disconnec-
tion serves to separate emotions from attachment-related situations
and the people arousing them (e.g. insecurity). Segregated systems
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Journal of Affective Disorders 210 (2017) 130–138
refer to fearful or even traumatizing material (e.g. helplessness), that
must be locked away from conscious awareness and thus put indivi-
duals at risk for dysregulation. Based on these rating scales, the AAP
derives four main attachment groups: secure, dismissing, preoccupied,
and unresolved. Secure attachment (F) is characterized by a high
agency of self, a lot of connectedness and synchrony in the narratives.
Insecure-dismissing (Ds) or insecure-preoccupied (E) individuals de-
monstrate either functional or absent relationships and they primarily
use deactivation (in case of Ds) or cognitive disconnection (in case of E)
to successfully shift attention away from attachment-related stressors.
In contrast to these organized attachment patterns (F, Ds, E),
individuals with an unresolved attachment (U) can be considered as
disorganized as they fail to re-organize fearful or traumatizing material
(segregated systems) and thus get flooded by their attachment fears.
Psychometric properties of the AAP are excellent (George and West,
2001, 2004, 2012). AAP interjudge reliability between independent
judges showed agreement of 90% (kappa=.85, p=.000, n=144). Test-
retest reliability was calculated based on 69 participants (39 females,
30 males) who completed the AAP retest 3 months following the
original AAP administration. 58 participants (84%) were classified in
the same attachment group categories (kappa=.78, p=.000). Verbal
intelligence and social desirability were not related to AAP classifica-
tions (George and West, 2012). The comparison with the Adult
Attachment Interview (George et al., 1985; Main and Goldwyn,
1985–1996; George et al., 1996), another established measure to
assess attachment representation (see George and West, 2012;
Buchheim and George, 2012), showed convergent validity for the four
major attachment groups of 90% (kappa=.84, p < .000) between the
two attachment measures (AAP and AAI). Convergent agreement for
two group classifications was 97% (kappa=.88, p < .000) (George and
West, 2011, 2012; Buchheim and George, 2012; George and Buchheim,
2014).
2.3. Cyberball game
The Cyberball game is a virtual ball tossing game (Williams et al.,
2000). The standardized experimental setting used in this study has
been reported in other publications (see Jobst et al., 2014). First, the
participants were prepared for a computer game that they play together
with two other players connected via the internet, though in reality they
are computer-controlled and represented by name and picture (Fig. 1).
After getting the ball three times, an inclusion rate of 10%, the
participants were excluded for the rest of the game. Immediately after
finishing the Cyberball game participants completed a paper-and-
pencil questionnaire that contained the Need-Threat Scale (NTS,
Williams et al., 2000; Zadro et al., 2006; German version: Grzyb,
2005; Staebler et al., 2011) to ascertain impairment of four funda-
mental needs during the game that were measured with three items per
scale: belonging (e.g. “I felt rejected.”), self-esteem (e.g. “I felt good
about myself.”), control (e.g. “I felt powerful.”) and meaningful
existence (e.g. “I felt nonexistent.”). Negative items were reverse
scored: Higher values indicated more need satisfaction. Negative mood
was assessed through eight items (e.g. “sad”, “bad”, “happy”). Positive
items were reverse scored. There were three control items to confirm
the participants’ perception of being excluded (“I was excluded.”, “I was
ignored.”, open question to estimate the percentage of throws they
received during the Cyberball interaction). Unless otherwise stated, all
questions were rated on 5-point Likert scales (1=not at all until 5=very
much so). Responses were averaged to create the overall indexes. The
internal consistency of the need items and the resulting Cronbach's α
(total scale: α=.83; fundamental needs: α=.51 until α=.83; overall need
satisfaction: α=.84, mood: α=.82, control items: α=.88) were compar-
able to former findings (e.g. Williams, 2005; Wirth et al., 2010;
Staebler et al., 2011).
The behavioral intentions after the game were assessed with a list of
choices as previously reported (Staebler, 2008). The participants were
C. Bauriedl-Schmidt et al. Journal of Affective Disorders 210 (2017) 130–138

Table 2
Responses to Cyberball in depressive vs. healthy individuals.

Comparisons: CD ED HC Between groups

n=28 n=19 n=28

Mean (SD) Mean (SD) Mean (SD) χ2 p

Fulfillment of needs (NTS)

Overall need satisfaction 2.48 (.72) 2.67 (.75) 2.83 (.74) 2.801 .246
Belonging 2.85 (1.10) 3.09 (1.15) 3.17 (1.16) 1.241 .538
Self-esteem 2.37 (.93) 2.45 (.94) 3.00 (.93) 7.497 .001**
Meaningful existence 3.33 (1.21) 3.44 (1.21) 3.39 (1.26) .115 .944
Control 1.52 (.58) 1.72 (.78) 1.75 (.77) .979 .613
Negative mood 3.14 (.82) 2.93 (.69) 2.27 (.74) 16.383 .000**

Control items
“I felt excluded/ ignored” 3.50 (1.15) 2.94 (1.40) 3.25 (1.34) 2.210 .331
“I owned the ball” (%) 11.62 (6.47) 14.50 (16.69) 9.82 (6.06) 1.145 .564

List of behavioral intentions

Pleasant activities1 .31 (.30) .25 (.25) .36 (.26) 2.024 .364
Passive behavior1 .33 (.31) .40 (.36) .14 (.23) 8.975 .011*

Annotations: Means were compared with Kruskall-Wallis-Test (df =2). For the List of Behavioral Intentions only the comparisons that are statistically significant for one or two groups
are displayed. 1 = scores of behavioral items could range between 0 and 1.
*= 2-sided (asymptotic) significance according to level of significance set at α=.05, **= 2-sided (asymptotic) significance according to level of significance set at α=.01.

asked whether or not they agreed with each of the 21 given behaviors
(e.g. to sleep, to hurt s.b.). The individual intentions were clustered
according to Staebler (2008) to eight categories (e.g. passive intentions,
pleasant activities, aggression towards others, verbalize the rejection).
All mentioned measures are listed in the left column in Table 2.

2.4. Data analysis

SPSS software version 17 was used for statistical analysis (SPSS

Inc., Chicago, IL 60606, USA). The decision on whether to apply a
parametric or non-parametric procedure for the metric variables was
made with the Kolmogorov-Smirnov-test and the assessment of the
respective histogram. The Kruskal-Wallis- or Mann-Whitney-U test as
non-parametric or respectively the F- or T-test as parametric procedure
was applied to contrast the subgroups. For the non-metric variables,
the Pearson χ2-test (or Fisher's Exact Probability Test, when applic-
able) was employed. Bonferroni-Holm-corrections were used in the
three comparisons between the CD, ED, HC groups to avoid accumula-
tion of alpha-errors.

3. Results

3.1. Early childhood trauma (CTQ)

With respect to childhood trauma both CD and ED patients differed

significantly from the HC group. Patients reported more emotional,
physical, and sexual abuse as well as more emotional neglect in the
CTQ. Moreover, the ED participants showed higher scores on physical
neglect than the HC and CD groups (HC: p=.001, CD: p=.040). The ED
and CD subgroups did not differ from each other with regards to
amount of sexual, physical, emotional abuse and emotional neglect
(sexual: p=.793, physical: p=.177, emotional abuse: p=.275, emotional
neglect: p=.301) (Table 1, B).
Fig. 2. a: Distribution of “secure”/”insecure” classifications (percentage) in CD, ED, HC
b: Distribution of “organized”/”disorganized” classifications in CD, ED, HC.
3.2. Distribution of adult attachment representations
Cross tables show that the proportions did not significantly differ
In the ED and CD groups, insecure attachment representation was between the two depressive groups, but between the control and each
predominant: 95.5% of the ED and 96.3% of the CD patients were depression group (p > .05, Pearson χ2=21.344, df=2, p=.000). The
classified as either dismissing, preoccupied, or unresolved. In the HC, predominant representation in the HC group was the organized
the distribution of attachment patterns was more balanced: 48.1% classification (Fig. 2b), i.e. 88.9% (vs. 11.1% disorganized subjects,
secure vs. 51.9% insecure individuals (Fig. 2a).

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C. Bauriedl-Schmidt et al.
cross table shows significant difference: p > .05), whereas in the clinical
groups we found a more equal distribution of organized (secure,
insecure-dismissing, insecure-preoccupied)/ and disorganized indivi-
duals. 63.6% of the ED and 66.7% of the CD individuals were rated as
organized (Fig. 2b). The cross table demonstrates that the overall
frequency distribution of organized/disorganized classifications shows
a non-significant trend between the three groups (χ2=5,050; df=2;
p=.080). However, there was no difference between CD and ED
patients in this respect.
3.3. Reactions to cyberball
The overall need satisfaction as well as the NTS scores in the
individual needs for “belonging”, “meaningful existence” and “control”
did not differ significantly among the three diagnostic groups
(overall: p=.246, belonging: p=.538, meaningful existence: p=.944,
control: p=.613). Only the CD, but not the ED individuals showed a
significantly lower score in need for self-esteem than the HC subjects,
i.e. reported more need threat for self-esteem (NTS: self-esteem:
U(nCD=28,nHC=28)=233.000, p=.005; U(nED=19,nHC=28)=179.000,
p=.028, U(nED=19,nCD=28)=179.000, p=.380). Both depression
group reported significantly higher scores in negative mood
(U(nCD=29,nHC=28)=169.000, p=.000; U(nED=19,nHC=28)=127.500,
p=.003, U(nED=19,nCD=29)=188.500, p=.263, 1-sided asymptotic sig-
nificance). The subgroups were similar on the extent they felt ignored/
excluded, and on the amount of perceived ball tosses (ignored/
excluded: p=.331, ball tosses: p=.564) (Table 2).
Regarding behavioral intentions after Cyberball, CD and ED
patients chose more passive intentions (e.g. “to sleep”, “to smoke”)
than the HC after playing the game (U(nCD=29,nHC=29)=276.000,
p=,009, U(nED=19,nHC=29)=162.500, p=,005, U(nCD=29,nED=19)
=249.500, p=,272, 1-sided asymptotic significance, Bonferroni-Holm-
corrected for three comparisons) (Table 2).
Due to the small sample sizes of single attachment categories we
grouped both CD and ED subjects together in order to investigate the
differences in the reactions of depressed individuals with organized vs.
disorganized attachment representations. Because of the explorative
character of this section, we tested 2-tailed. The significant differences
and non-significant trends (significance levels ranging between .051
and .100) are mentioned here. The organized depressive individuals
reported a higher self-esteem (p=.094) in the NTS, though the overall
need satisfaction did not differ between both groups (p=.143).
Furthermore the organized subjects picked more intentions to involve
into pleasant activities (e.g. to meet friends) and to verbalize the
rejection (e.g. to ask why s/he was rejected) in the List of Behavioral
Intention than the disorganized individuals (pleasant activities:
p=.048, verbalize the rejection: p=.056). The disorganized depressive
subjects in turn felt more ostracized and reported a higher amount of
negative mood (NTS: ignored: p=.042, mood: p=.025). Moreover, they
chose more intentions to passive behavior and to aggression towards
others (aggression: p=.082, passive behavior: p=,028, 2-sided asymp-
totic significance). The aggression towards others variable includes e.g.
the intention to hurt somebody or to damage something. Additionally
the disorganized depressive individuals displayed a higher score in the
CTQ score emotional neglect (Mean ± SD: organized: 12.10 ± 4.02,
disorganized: 14.76 ± 5.48, U(norganized=31,ndisorganized=17)=184.000,
p=.086) (Table 3).
4. Discussion
To our knowledge, this is the first study to investigate the
differences in two groups of CD and ED inpatients with regards to
the three levels: traumatic experiences in biography, mental represen-
tations of attachment (AAP, George et al., 1999; George and West,
2012) and their reactions to social exclusion (Cyberball, Williams and
Jarvis, 2006). The groups were characterized by biographical, socio-
135
Journal of Affective Disorders 210 (2017) 130–138
emotional, resilience parameters as well as described in terms of
symptoms, comorbidity, present psychotropic treatment and course
of disease. Furthermore, we evaluated interpersonal trauma using the
CTQ questionnaire (Bernstein and Fink, 1998) to analyze differences
among the depressive subgroups.
The similar extent of impairment in CD and ED subgroups
regarding symptoms, course of disease, biography, socio-emotional
parameters (CTQ, AAP) contradicts previous findings and our hypoth-
eses 1 and 2, that CD individuals would report the most childhood
trauma and would show the highest amount of unresolved trauma in
their attachment representations. We cannot conclude here, that ED is
a less severe form of depression (Lizardi et al., 1995; Wiersma et al.,
2009; Schramm et al., 2011). This might be due to the recruitment of
ED from a psychiatric hospital inpatient setting. Accordingly, it can be
assumed, that the psychiatric inpatients suffering from ED were more
traumatized and ill (i.e. even more physical neglect than CD inpatients,
average amount of depressive episodes: n=3) than the patients in the
cited studies above. Because recent research and theory propose that
ED and CD are two fundamental different diseases (APA, 2013; Jobst
et al., 2016), these results indicate that with regards to a subgroup of
the severely depressive patients it might be difficult to reliably select
between ED and CD. We might assume that a part of ED patients may
later develop a chronic form of depression (Brockmeyer et al., 2015).
To include the assessment of cognition, motivation and behavior in a
standardized interpersonal situation (e.g. AAP, Cyberball) might
provide additional helpful diagnostic information.
However, the expected discrepancies between both depression
groups and the HC group could be verified. As described in the
literature, the relevance of interpersonal childhood trauma, particularly
emotional neglect or abuse, was confirmed: Both depressive groups
reported a higher amount of adverse childhood experiences (CTQ),
particularly emotional trauma, than the HC (Bowlby, 1988; APA, 2000;
McCullough, 2003; Chapman et al., 2004; Chavustra and Cloitre, 2008;
D’Andrea et al., 2012; Banducci et al., 2013; Holmes, 2013). This is
consistent with the description of D’Andrea et al. (2012), who linked
interpersonal childhood trauma with subsequently arising interperso-
nal problems that might result in the development of depression
(Coyne, 1976; Kessler et al., 1995; McCullough, 2003; Jonsson et al.,
2011). As expected, the accumulation of interpersonal trauma in
biography was reflected by higher proportions of unresolved trauma
in the AAP narratives and insecure representations in both clinical
groups (George et al., 1999; Chapman et al., 2004; Buchheim et al.,
2013; Juen et al., 2013). Only 3.7% for CD (4.5% ED, 48.1% HC)
individuals were classified as secure. Moreover, the disorganized
category is more prevalent in the depressive groups as well: 33% in
the CD group (36% ED) contrasted with 11% in the HC subjects. This
tendency fits with former findings, demonstrating that the disorganized
category is not only relevant in CD (Buchheim et al., 2013; West and
George, 2002), but also in psychiatric ED (Bakermans-Kranenburg and
van IJzendoorn, 2009). These discrepancies might again be explained
through differences in psychiatric vs. non-psychiatric samples.
Therefore hypothesis 1 and 2 could only be affirmed for differences
between HC and both depression groups with regards to childhood
trauma and unresolved trauma in the attachment representations.
Although all groups judged the ball ownership similarly and felt
excluded/ignored to a similar extent only the depressive groups
reported significantly higher scores in negative mood during
Cyberball and only in the CD group Cyberball had a significantly
higher impact on self-esteem. The comparable effects of Cyberball on
the overall need satisfaction (i.e. especially on belonging, control,
meaningful existence, NTS, Williams et al., 2000, right column in
Table 2) of the three groups corresponds with the assumptions of the
temporal need-threat model and previous findings (Williams, 2009),
that the automatic need-decreasing reaction after social exclusion is
trans-individual and independent from personal characteristics.
Depression-specific imprinting was found too: The lower score in the
C. Bauriedl-Schmidt et al.
Table 3
Responses to cyberball in organized vs. disorganized depressive individuals.
Scales Organized (n=31)
Mean ± SD
Immediate effect of ostracism
Overall need satisfaction (NTS) 2.69 ± .72
Self-esteem (NTS) 2.60 ± .96
Negative Mood 2.86 ± .70
“I felt excluded”/ “I felt ignored” 3.00 ± 1.22
List of Behavioral Intentions1
Pleasant activities .36 ± .27
Address the rejection .40 ± .34
Aggression towards others .02 ± .09
Passive Behavior .28 ± .32
Annotations: Means were compared with Mann-Whitney-U-Test. Only the comparisons that are statistically significant for one or two groups are displayed. 1 = scores of behavioral items
could range between 0 and 1.
*=2-sided (asymptotic) significance according to level of significance set at α=.05, SD = Standard Deviation.
need for self-esteem in CD subjects is seen as characteristic that
matches the conceptualization of depression (McCullough, 2003;
Ravitz et al., 2007; Davison et al., 2007). Both depressive groups
displayed a higher extent of negative mood. The predominant inten-
tions in the depressive individuals for passive behavior can be inter-
preted as a marker for a regressive state that is thought to be linked to a
pre-operational status (McCullough, 2003). Overall, our hypothesis 3
can be affirmed, that in the social exclusion paradigm, the depressive
individuals responded more dysfunctional and that the CD individuals
might be most impaired.
Our results indicate that the attachment organization of represen-
tations plays a role in how depressive individuals regulate their
emotions in reaction to a social stressor (Cyberball). The subjects with
organized attachment representations (secure, insecure-dismissing or
insecure-preoccupied) displayed a higher self-esteem (NTS, non-sig-
nificant trend) and more constructive behavioral intentions (i.e.
pleasant behavior, address the rejection). This can be seen as a general
ability to regulate the emotional state through considering steps that
heigthen chances to feel included again. Moreover, the disorganized
individuals scored higher in negative mood (NTS), and showed more
intentions to engage in passive behavior and aggression, though the
latter is only a non-significant trend. These findings can be seen
carefully as indicators for emotional dysregulation in the disorganized
group (e.g. Holtzheimer and Mayberg, 2011). The disorganized in-
dividuals (unresolved trauma) however felt more ostracized and
additionally scored significantly higher than the organized patients in
the CTQ dimension emotional neglect. Whether this is associated with
a heightened sensitivity towards cues of social exclusion and rejection
should be further investigated (Downey and Feldman, 1996; Staebler
et al., 2008; Jobst et al., 2014).
Our findings from the two paradigms AAP and Cyberball can be
integrated into psychotherapeutic treatment of severely ill patients.
Insecurely attached, especially disorganized depressive individuals will
benefit from interventions that support them to acquire abilities to
reflect the states of mind of self and others (e.g. Fonagy et al., 2004).
The enhancement of “agency of self”, contributing to self-esteem, will
help the depressive individual to develop a more functional coping with
painful social interactions, like threatening ostracism, and learn how to
increase the chances to feel socially included (Williams, 2009; George
and West, 2012; Brockmeyer et al., 2015). The assessment of attach-
ment representations may also stimulate CBASP therapists, e.g. to
adjust expressions of disciplined personal (therapeutic) involvement to
the patient's extent of interpersonal traumatization (McCullough,
2003).
We have to consider several limitations in this study. These are
overrepresentations of male participants, small and differing sample
Journal of Affective Disorders 210 (2017) 130–138
Disorganized (n=16) Statistic p-value
Mean ± SD
2.41 ± .72 U(norganized=26,ndisorganized=15)=156.500 .143
2.10 ± .85 U(norganized=28,ndisorganized=16)=156.500 .094
3.41 ± .84 U(norganized=28,ndisorganized=16)=132.500 ,025*
3.77 ± 1.18 U(norganized=24,ndisorganized=15)=110.500 ,041*
.20 ± .28 U(norganized=29,ndisorganized=16)=151.500 .048*
.22 ± .41 U(norganized=29,ndisorganized=16)=158.500 ,056
.10 ± .20 U(norganized=29,ndisorganized=16)=189.000 ,082
.50 ± .32 U(norganized=29,ndisorganized=16)=147.500 ,028*
sizes between the participants of that study due to differing phases in
the whole study. The uneven distribution secure/insecure and orga-
nized/disorganized across groups does not allow an analysis of all
attachment representations across all groups. The study should be
replicated with larger, but more continuous and representative samples
to be able to investigate the interaction between ostracism and
attachment in the two depression groups. The psychotropic medication
in inpatients might have affected their ability to experience or react to
social pain, as shown for the painkiller paracetamol (Eisenberger,
2012; Hartgerink et al., 2015). This should be taken into account. In
contrast to previous results, we found that ED and CD participants
were similarly ill and displayed almost identical distributions of
attachment patterns (Klein et al., 1999; Keller et al., 2000;
McCullough, 2003; Wiersma et al., 2011; Jonsson et al., 2011;
Buchheim and George, 2012; Buchheim et al., 2012). For further
research, the ED group should be more homogeneous, for instance
restricted to one or two former episodes and/or be recruited from an
outpatient setting. We did not assess neutral or inclusionary baselines
for mood, need fulfillment and behavioral intentions in depressive
individuals (Jobst et al., 2015). Thus we cannot specify if the
differences found between the groups reflect effects of the Cyberball
manipulation or if they are due to pre-existing negative mood,
decreased need fulfillment for self-esteem and passivity in depressive
individuals that in terms of ceiling respectively floor effects might have
been difficult for Cyberball to affect.
5. Conclusion
Due to the combination of two emotion inducing paradigms (AAP,
Cyberball), differing patterns of social stress management were identi-
fied in the combined depression group that are in accordance with the
current theory and attachment respectively depression related research
(e.g. Eisenberger et al., 2003, 2011; Eisenberger, 2012; Holtzheimer
and Mayberg, 2011; Buchheim and George, 2012; overview: Holmes,
2013; Gander and Buchheim, 2015). Specific resources for emotion
regulation and strategies to cope with the social stress (i.e. feeling of
self-esteem, intention to constructive behavior) as well as dysregulation
(i.e. negative mood, intention for dysfunctional behavior) have been
identified that provide fruitful contributions for diagnosis and attach-
ment specific therapeutic interpersonal interventions. The specific
effect that social exclusion has on the intra- and interpersonal
responses of depressive individuals as well as the role of moderator
variables (e.g. attachment organization, rejection sensitivity) should be
clarified in larger samples and a manipulation design that encompasses
neutral, inclusion and exclusion conditions.
136
C. Bauriedl-Schmidt et al.
Role of funding sources
There was no involvement of a funding source.
Conflicts of interest
All authors declare that they have no conflicts of interest.
Acknowledgement
We thank Babette Renneberg for her kind help with establishing the
cyberball paradigm. Moreover, we thank the psychologists, and stu-
dents, who provided support for the study: Anna Albert, Amalie
Boldischar, Tanja Daltrozzo, Eva Holzamer, Constance Jacob, Ariane
Klughardt, Aischa Letters, Annika Plöger, Anja Palagyi, and Charlotte
Wink. This work is part of the PhD thesis of C. Bauriedl-Schmidt.
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