Attachment styles in adult intimate relationships: comparing women with bulimia nervosa symptoms, women with depression and women with no clinical symptoms

Attachment in individuals with eating disorders compared to community controls: A systematic review and meta-analysis

OBJECTIVE

Individuals with eating disorders are known to have higher rates of insecure attachment compared to community controls, but the factors underlying this finding are poorly understood. We conducted the first meta-analysis comparing attachment in eating disorder samples compared to community controls that included quality assessment, publication bias and moderation analysis.

METHOD

We pre-registered our meta-analysis (CRD42019146799) and followed PRISMA guidelines. We searched PsychINFO, Embase, Medline, CINAHL, and Scopus for publications. Attachment scores were extracted, and Cohen's d calculated for each study using a random effects model.

RESULTS

In total, 35 studies were included in the meta-analysis and six studies were summarized in a narrative review. Eating disorder samples showed higher rates of insecure attachment compared to community controls, with a large effect size, across measurement methods and different attachment dimensions. Blinding of assessors moderated effect sizes for attachment interview studies, but no other moderators were significant.

DISCUSSION

Risk of insecure attachment is elevated in individuals with eating disorders, albeit heterogeneity is high and largely unexplained. Clinicians may need to take this into account in their work, particularly given the association between attachment insecurity and challenges to therapeutic alliance. Future studies comparing eating disorder samples with community samples should control for general psychopathology.

PUBLIC SIGNIFICANCE

Attachment is a broad concept referring to a person's thoughts, feelings and behaviors in relation to close others. This systematic review and meta-analysis found that individuals with eating disorders are lower in attachment security than community controls, regardless of attachment construct or measurement approach. Attachment may be relevant in influencing eating disorder recovery, the development of therapeutic alliance, and potentially clinical outcomes, although more research is needed.

The role of the perception of family environment in relation to body dissatisfaction, disordered eating and difficulties in close relationships

PURPOSE

Invalidating childhood environments have been characterised as those in which caregivers do not validate a child's personal experiences and the communication of emotions is considered inappropriate, being either ignored or punished. The current study assessed the relationships among invalidating childhood environments, body dissatisfaction, disordered eating and difficulties in close relationships in a sample of college students.

METHODS

In this study, 362 non-clinical participants with ages ranging from 17 to 25 years (M = 20.02, SD = 1.51) completed self-report measures.

RESULTS

Difficulties in close relationships, body dissatisfaction and disordered eating were significantly higher in invalidating families than in validating families. Invalidating childhood environments were associated with higher body dissatisfaction and disordered eating, and both associations were mediated by difficulties in close relationships. Finally, body dissatisfaction mediates the effects of BMI and difficulties in close relationships on eating disorder symptoms.

CONCLUSIONS

Perceived experiences of invalidation in childhood may be associated with eating disorder symptomatology. In addition, difficulties in close relationships during adulthood possibly contribute to the emergence of eating disorder symptoms.

LEVEL OF EVIDENCE

Level V, descriptive study.

Perceived Conflict and Support Among Women with Bulimia Nervosa Compared to Women with Depression and Healthy Controls: An Experimental Manipulation

Objective: Women with bulimia nervosa (BN) often present with interpersonal difficulties. It is unknown whether these difficulties primarily are based on distorted social perceptions, and whether they are unique to BN. The current study used a repeated-measures design to compare perceptions of interpersonal interactions for participants with BN, depression (DEP), and healthy controls (HCs). We hypothesized that women with BN would perceive more conflict and less support than HCs. Analyses comparing BN and DEP were exploratory.

Method: Participants with BN (n = 27) or DEP (n = 26) and HCs (n = 27) rated perceived conflict and support for 24 vignettes depicting social interactions that varied in levels of these two constructs. Participants also completed relationship quality/satisfaction questionnaires.

Results: Multilevel model analyses revealed that the BN group perceived greater conflict relative to HCs. There also were significant interactions, with BN participants more greatly impacted by high support. There were no differences between DEP and BN groups.

Discussion: Overall, BN participants perceived more conflict than HCs, but differences were attenuated when level of social support was high. Helping women with BN tolerate discomfort associated with any amount of perceived conflict and/or low support may be an important treatment target.

Eating disorders in adolescence: attachment issues from a developmental perspective

In the present article we review findings from an emerging body of research on attachment issues in adolescents with eating disorders from a developmental perspective. Articles for inclusion in this review were identified from PsychINFO (1966-2013), Sciencedirect (1970-2013), Psychindex (1980-2013), and Pubmed (1980-2013). First, we will outline the crucial developmental changes in the attachment system and discuss how they might be related to the early onset of the disease. Then we will report on the major results from attachment studies using self-report and narrative instruments in that age group. Studies with a developmental approach on attachment will be analyzed in more detail. The high incidence of the unresolved attachment pattern in eating disorder samples is striking, especially for patients with anorexia nervosa. Interestingly, this predominance of the unresolved category was also found in their mothers. To date, these transgenerational aspects are still poorly understood and therefore represent an exciting research frontier. Future studies that include larger adolescent samples and provide a more detailed description including symptom severity and comorbidity would contribute to a better understanding of this complex and painful condition.

Pre-treatment attachment anxiety predicts change in depressive symptoms in women who complete day hospital treatment for anorexia and bulimia nervosa

OBJECTIVES

Individuals with eating disorders are prone to depressive symptoms. This study examines whether depressive symptoms can change in women who complete intensive day treatment for anorexia and bulimia nervosa (BN), and whether these changes are associated with pre-treatment attachment insecurity.

DESIGN

Participants were 141 women with anorexia nervosa restricting type (n = 24), anorexia nervosa binge purge type (n = 30), and BN (n = 87) who completed a day hospital treatment programme for eating disorders. They completed a pre-treatment self-report measure of attachment, and a pre-treatment and post-treatment self-report measure of depressive symptoms.

RESULTS

Participants experienced significant reductions in depressive symptoms at post-treatment. Eating disorder diagnosis was not related to these improvements. However, participants lower in attachment anxiety experienced significantly greater improvement in depressive symptoms than those who were higher in attachment anxiety.

CONCLUSIONS

These results suggest that clinicians may tailor eating disorders treatments to patients' attachment patterns and focus on their pre-occupation with relationships and affect regulation to improve depressive symptoms.

PRACTITIONER POINTS

That depressive symptoms can decrease in women who complete day hospital treatment for anorexia and BN. That improvements in depressive symptoms do not vary according to eating disorder diagnosis in these women. That patients who complete treatment and who have higher attachment anxiety experience less improvements in depressive symptoms compared to those lower in attachment anxiety. That clinicians may attend to aspects of attachment anxiety, such as need for approval and up-regulation of emotions, to improve depressive symptoms in female patients with eating disorders.

Anorexia and attachment: dysregulated defense and pathological mourning

The role of defensive exclusion (Deactivation and Segregated Systems) in the development of early relationships and related to subsequent manifestations of symptoms of eating disorders was assessed using the Adult Attachment Projective Picture System (AAP). Fifty-one DSM-IV diagnosed women with anorexia participated in the study. Anorexic patients were primarily classified as dismissing or unresolved. Quantitative and qualitative analyses of defensive exclusion were carried out. Results showed potential benefits of using the AAP defense exclusion coding system, in addition to the main attachment classifications, in order to better understand the developmental issues involved in anorexia. Discussion concerned the processes, such as pathological mourning, that may underlie the associations between dismissing and unresolved attachment and anorexia. Implications for developmental research and clinical nosology are discussed.

Compensatory weight control behaviors of women in emerging adulthood: associations between childhood abuse experiences and adult relationship avoidance

OBJECTIVE

To examine correlates of compensatory weight control behaviors among women in transition between adolescence and adulthood.

PARTICIPANTS

The authors recruited a sample of undergraduate women (N = 759) at a large northwestern university during the 2009-2010 academic year.

METHODS

Logistic regression was used to assess relations among childhood abuse, psychosocial functioning, adult dating relationship factors, and women's endorsement of compensatory weight control behaviors.

RESULTS

The final model reliably distinguished between participants who endorsed versus denied use of compensatory behaviors (χ(2)[5, N = 747] = 36.37, p < .001), with global psychosocial functioning and relationship avoidance accounting for the most variance.

CONCLUSIONS

These findings illustrate the importance of considering childhood abuse histories and adult relationships while assessing young women's compensatory weight control behaviors.

Eating psychopathology amongst athletes: links to current attachment styles

The aims of the study were two-fold; first to determine the associations between current attachment styles, and eating psychopathology amongst athletes, and second to simultaneously assess the mediating effects of self-esteem, perfectionism, and depression in this association. Four hundred and eleven British athletes completed self-report instruments pertaining to eating psychopathology, attachment styles, self-esteem, depression, and perfectionism. Athletes who scored highly on both avoidant and anxious attachment styles, reported elevated eating psychopathology scores. However, such associations were indirect and mediated via athletes' levels of self-esteem, self-critical perfectionism, and depression, with self-esteem and depression identified as more salient mediators than self-critical perfectionism. The current findings provide evidence to suggest that insecure attachment styles influence athletes' eating psychopathology via their impact on self-esteem, depression, and self-critical perfectionism. Moreover, self-esteem and depression may play more significant role in transferring the impact of insecure attachment styles on elevated eating psychopathology.

As relações de vinculação e a imagem corporal: exploração de um modelo

Pretende-se analisar a contribuição diferencial dos principais contextos de desenvolvimento (relação parental e de pares) na forma como os adolescentes experienciam a relação com o seu corpo. A amostra é constituída por 690 adolescentes e jovens adultos (242 meninos e 448 meninas), com idades compreendidas entre os 15 e os 23 anos (M= 17,8 e DP=2,00). Os resultados do modelo de predição revelaram que o gênero e a vinculação romântica foram as variáveis que mais contribuíram para a variação da variável imagem corporal. Foi observado um efeito de mediação entre a vinculação aos pais e a imagem corporal através da relação romântica e de amizade. Os resultados sublinham a necessidade de se compreender a vivência corporal nos contextos interpessoais.

Application of the Transdiagnostic Cognitive-Behavioral Model of Eating Disorders to the Athletic Population

The purpose of this study was twofold: to explore the utility of components related to the transdiagnostic cognitive-behavioral model of eating disorders within an athletic population and to investigate the extent to which the model can be applied across gender, sport type, and performance standard to explain eating psychopathology. Five hundred and eighty-eight (N = 588) male and female British athletes completed a battery of self-report instruments related to eating psychopathology, interpersonal diffculties, perfectionism, self-esteem, and mood. Structural equation modeling revealed that eating psychopathology may arise from an interaction of interpersonal diffculties, low self-esteem, high levels of self-critical perfectionism, and depressive symptoms. Analysis further highlighted that the manner in which eating psychopathology may arise is invariant across athletes’ sport type and performance standard, but not across gender. The current findings suggest that the tested components of the transdiagnostic cognitive-behavioral model are pertinent and useful in explaining eating psychopathology among athletes.

Attachment insecurity predicts eating disorder symptoms and treatment outcomes in a clinical sample of women

We examined the extent to which attachment insecurity was related to eating disorder (ED) symptoms, and predictive of treatment outcomes. Women diagnosed with anorexia nervosa (AN) restricting subtype (ANR), AN binge purge subtype (ANB), or bulimia nervosa (BN) completed an attachment scale pretreatment, and ED symptom scales pretreatment (N = 243) and post-treatment (N = 157). A comparison sample of 126 non-ED women completed attachment scales on 1 occasion. Those with EDs had significantly higher attachment insecurity than non-ED. ANB was associated with higher attachment avoidance compared with ANR and BN, and higher attachment anxiety compared with BN. Higher attachment anxiety was significantly related to greater ED symptom severity and poorer treatment outcome across all EDs even after controlling for ED diagnosis. Attachment dimensions substantially contribute to our understanding of ED symptoms and treatment outcome. Addressing attachment insecurity when treating those with EDs may improve treatment outcomes.

The utility of considering interpersonal problems in the assessment of bulimic features

Previous research suggests that heterogeneity in bulimic features can be explained in part by pathoplastic, or varying, interpersonal problems. The present study compared groups of women with bulimic features (N=110) defined by varying interpersonal problems (warm-dominant, warm-submissive, cold-submissive, or cold-dominant) with regard to comorbid psychopathology, personality characteristics, and the influences of dietary restraint and negative affectivity on bulimic psychopathology. As predicted, group differences were not explained by severity of eating-related pathology, socially desirable responding, or the interpretability of interpersonal profiles, although groups unexpectedly differed in depressive symptoms. The warm-submissive group had highest scores on adaptive personality characteristics, including, agreeableness, extraversion, and conscientiousness. As hypothesized, the influence of negative affect and dietary restraint on bulimic symptoms differed as a function of interpersonal style, perhaps suggesting that interpersonal problem heterogeneity may mark different etiological pathways for bulimic psychopathology. Finally, interpersonal problems incremented bulimic features in predicting depressive symptoms. Overall, these results highlight the added value of considering pathoplastic interpersonal problems in addition to clinical diagnoses in the assessment of eating disorders.

Early maternal adjustment in women with eating disorders

OBJECTIVE

To study early adaptation to motherhood in mothers with eating disorders (ED) before pregnancy.

METHOD

Forty-four nulliparous nonsmoking women with ED before pregnancy (24 anorexia nervosa, 20 bulimia nervosa) and 67 controls were recruited from the same prenatal clinics. Three months after delivery, the women completed the maternal adjustment and maternal attitude questionnaire (MAMA) and were asked about mental health problems postpartum.

RESULTS

Ninety-two percent of mothers with ED before pregnancy reported problems regarding their maternal adjustment compared to 13% in the control group (p < 0.001), whereas there were no differences between the subgroups of ED and between those with and without verified relapse of ED during pregnancy. Fifty percent of mothers with previous ED reported that they had been in contact with health services after delivery because of depression or other mental problems and these women had significantly higher MAMA score than patients not reporting such contact with health services (p < 0.001).

CONCLUSION

Adjustment to motherhood was clearly impaired and related to mental problems in mothers with ED before pregnancy.

Pathoplasticity of bulimic features and interpersonal problems

OBJECTIVE

Recent research suggests that interpersonal problems and some forms of psychopathology are pathoplastic, or that they mutually affect one another in nonetiological ways. In the current study, the pathoplasticity of bulimic features and interpersonal problems was tested.

METHOD

Inventory of Interpersonal Problems-64 data from 130 women with scores in the top quartile on the Bulimia scale of the Eating Disorder Inventory-2 from a sample of 517 college undergraduates were cluster analyzed. Age, weight, and scores on psychopathology scales were tested for mean differences across the four quadrants of the interpersonal problems circumplex.

RESULTS

Consistent with the pathoplasticity hypothesis, cluster means did not differ on external variables. Furthermore, bulimic features and interpersonal problems independently predicted depression in the total sample.

CONCLUSION

The interpersonal problems reported in the current study suggest differential treatment process that could inform the therapeutic relationship and help prevent premature termination.

Symptom profile of major depressive disorder in women with eating disorders

OBJECTIVE

Based on the well-documented association between eating disorders (EDs) and affective disorders, the patterns of comorbidity of EDs and major depressive disorder (MDD) were investigated. The temporal relation between EDs and MDD onset was analyzed to determine differences in the course and nature of MDD when experienced prior to versus after the onset of the ED.

METHOD

Lifetime MDD and depressive symptoms were assessed in 1371 women with a history of ED. The prevalence of MDD was first explored across ED subtypes, and ages of onset of MDD and EDs were compared. Depressive symptoms were examined in individuals who developed MDD before and after ED onset.

RESULTS

The lifetime prevalence of MDD was 72.9%. Among those with lifetime MDD (n =963), 34.5% reported MDD onset before the onset of ED. Those who experienced MDD first reported greater psychomotor agitation (OR =1.53; 95%CI =1.14-2.06), and thoughts of own death (but not suicide attempts or ideation; OR =1.73; 95%CI =1.31-2.30). Among individuals who had MDD before ED, 26.5% had the MDD onset during the year before the onset of ED; 67% of individuals had the onset of both disorders within the same 3 year window.

CONCLUSION

Clinicians treating individuals with new-onset ED or MDD should remain vigilant for the emergence of additional psychopathology, especially during the initial 3 year window following the onset of the first disorder.

Attachment styles, memories of parental rearing and therapeutic bond: a study with eating disordered patients, their parents and therapists

Patients diagnosed with anorexia nervosa (n = 30) and bulimia nervosa (n = 27), their parents and therapists were recruited for this study aimed at examining differences between clinical groups and a control group (n = 35) in terms of attachment styles and perceptions of memories of parental rearing. Within the clinical groups, relations among these variables and therapeutic bond were explored. In addition, parents' and their daughters' attachment styles were compared. The results showed differences between clinical and control groups: the daughters in the control group reported lower levels of attachment anxiety compared to those of the clinical groups; their mothers exhibited higher security than mothers of anorectic patients and lower avoidance than mothers of bulimic patients. For the anorectic group, therapeutic bond was associated to higher father's emotional support and lower rejection; in the bulimic group, therapeutic bond was related to higher maternal emotional support and lower rejection as well as to lower paternal overprotection.