A review of the evidence regarding associations between attachment theory and experimentally induced pain

Could Relationship-Based Learnt Beliefs and Expectations Contribute to Physiological Vulnerability of Chronic Pain? Making a Case to Consider Attachment in Pain Research

Pain is an interpersonal and inherently social experience. Pain perception and administration of medical treatment all occur in a particular environmental and social context. Early environmental influences and early learning experiences and interactions condition the body's response to different threats (like pain), ultimately shaping the underlying neurophysiology. These early interactions and experiences also determine what situations are perceived as threatening, as well as our belief in our own ability to self-manage, and our belief in others to offer support, during perceived threats. These beliefs intrinsically drive the combination of behaviors that emerge in response to perceived threats, including pain. Such behaviors can be categorized into attachment styles. In this interdisciplinary review, we synthesize and summarize evidence from the neurobiological, psychobiological, psychosocial, and psychobehavioral fields, to describe how these beliefs are embedded in the brain's prediction models to generate a series of expectations/perceptions around the level of safety/threat in different contexts. As such, these beliefs may predict how one experiences and responds to pain, with potentially significant implications for the development and management of chronic pain. Little attention has been directed to the effect of adult attachment style on pain in research studies and in the clinical setting. Using interdisciplinary evidence, we argue why we think this interaction merits further consideration and research. PERSPECTIVE: This review explores the influence of attachment styles on pain perception, suggesting a link between social connections and chronic pain development. It aligns with recent calls to emphasize the social context in pain research and advocates for increased focus on adult attachment styles in research and clinical practice.

Can Sensory- and Attachment-Informed Approaches Modify the Perception of Pain? An Experimental Study

Accumulating evidence linking pain with both attachment and sensory processing variables introduces the possibility that attachment- and sensory-informed strategies may modify pain experiences. The aim of this study was to investigate this proposition using an experimentally induced pain procedure. Pain perceptions of individuals using either a sensory-informed (weighted modality) or an attachment-informed (secure base priming) coping strategy were compared with those of individuals using no designated coping strategy. An independent measures experimental study design was used with a convenience sample of 272 pain-free adults. Experimental participants (n = 156) were randomly allocated to either an attachment (n = 75) or a sensory (n = 81) intervention group. Data from these participants were compared to those of 116 participants involved in an earlier cold pressor study in which no coping strategy was used. All participants completed the same sensory, attachment, and distress questionnaires and participated in the same cold pressor pain test. ANCOVAs revealed that participants in the sensory- and attachment-informed intervention groups reported significantly higher pain thresholds than the control group. Participants allocated to the sensory group also reported higher pain intensity scores than the control group. There were no significant differences in pain tolerance between the three groups after controlling for covariates. While further research is required, findings encourage further consideration of sensory- and attachment-informed strategies for people anticipating a painful experience.

Attachment insecurity as a vulnerability factor in the development of chronic whiplash associated disorder - A prospective cohort study

OBJECTIVES

Attachment theory represents a dynamic model for understanding how pre-existing personality factors may contribute to the development of chronic pain and disability after whiplash injury. The aim of the present study was to investigate the impact of attachment insecurity on disability 6-months post-injury. It was hypothesized that: (1) levels of attachment insecurity assessed at baseline would predict levels of disability six months post-injury, and (2) both attachment dimensions (anxiety and avoidance) would moderate associations between pain and disability, and psychological distress and disability.

METHODS

Questionnaire data were collected consecutively from a 1-year cohort of whiplash-injured. Data were collected from the emergency room within 1-month post-injury and at follow up 6-months post-injury (n = 205).

RESULTS

Both attachment dimensions were significantly associated with physical and psychosocial disability. Moreover, when attachment avoidance and attachment axiety were at the mean value (0SD) and high (+1SD), there was a significant positive relationship between pain intensity and disability (physical and psychosocial), with the exception of attachment anxiety, that only moderated the association between pain intensity and psychosocial disability when high. Also, when attachment avoidance and attachment axiety were high there was a significant positive relationship between depression and disability. Finally, when attachment avoidance was at the mean level and high there was a significant positive relationship between pain-catastrophizing and psychosocial disability.

CONCLUSION

Although the effects sizes for the moderations were small, the results support claims that attachment insecurity, measurable before onset of injury, represents a valuable pre-trauma vulnerability for less optimal recovery after whiplash injury.

Sensitivity to CT-optimal, Affective Touch Depends on Adult Attachment Style

Affective touch supports affiliative bonds and social cognition. In particular, gentle, stroking touch, which has recently been associated with the C Tactile (CT) system, is typically perceived as pleasant and prosocial. However, it remains unknown whether pre-existing models of social relating influence the perception of CT-optimal touch. In this study (N = 44 adults), we examined how individual differences in attachment styles relate to the perception of CT-optimal touch, as well as to a different modality of interoception, namely heartbeat perception. Using the gold-standard assessment of attachment (Adult Attachment Interview), we found that insecure attachment was associated with reduced pleasantness discrimination between CT-optimal vs. non-CT optimal touch. Acknowledging the different traditions in measuring attachment, we also used a well-validated self-report questionnaire that pertains to explicit representations of current close relationships. Using this measure, we found that higher scores in attachment anxiety (but not attachment avoidance) were associated with reduced pleasantness discrimination between CT-optimal vs. non-CT optimal touch. Attachment patterns (in both measures) were not related to cardiac perception accuracy. These results corroborate and extend previous literature on CT-optimal touch and its relation with affiliative bonds and social cognition. Given that attachment was not related to perceived cardiac accuracy, these findings point to the specificity of the relationship between CT-optimal touch and attachment.

The impact of attachment insecurity on pain and pain behaviors in experimental pain

OBJECTIVES

Pain perception and pain behaviors are distinct phenomena with different functions. Pain behaviors are protective in their functions, which include eliciting empathy or caring behaviors from others. Moreover, pain behaviors are intertwined with interpersonal relationships with significant others, which is why attachment orientations have been suggested as interpersonal schemas moderating the association between pain and pain behaviors. The aim of the current study was to assess the impact of insecure attachment dimensions on pain behaviors in laboratory-induced pain.

METHODS

This experimental study included a sample of 60 patients with low back pain recruited from a large spine center in a hospital in Region of Southern Denmark. Patients were recorded on video during a cold pressor procedure and asked to rate their level of pain. Prior to the procedure, attachment orientations were assessed by the Revised Adult Attachment Scale. Two assessors independently coded the recorded video material for protective and communicative pain behaviors.

RESULTS

A positive correlation of moderate size was found between pain intensity and pain communication. As hypothesized, attachment anxiety moderated the association between pain and pain behaviors. A high level of attachment anxiety was associated with at weaker association between pain and pain behaviors. None of the attachment dimensions correlated with pain intensity or pain behaviors.

CONCLUSION

The results indicate that patients with high levels of attachment anxiety may downplay pain and communication thereof. This finding is of potential clinical importance, since pain communication, among others, serves the function of eliciting caring behavior from healthcare personnel.

Evaluation of the short form of "Experience in Close Relationships" (Revised, German Version "ECR-RD12") - A tool to measure adult attachment in primary care

Attachment theory helps us to understand patients´ health behavior. Attachment styles might explain patient differences in coping behavior, self-treatment, or patient-provider relationships. In primary care time constrains are relevant. A short instrument may facilitate screening and assessment in daily medical practice. The aim of this study was to evaluate a 12-item short version of the Experience in Close Relationships-revised (ECR-R-D) to be used in primary care settings. We included 249 patients from ten general practices in central Germany into a cross-sectional study. Exploratory factor analysis was performed to evaluate the factor structure of the ECR-items. Cronbach's alpha was used to assess internal consistency. The results related to the short form of the ECR are in line with those of the German full-length version of the measure (ECR-RD 36). Internal consistencies were in an adequate range. The ECR short form can be recommended as a screening measure of attachment styles in primary care.

Affective touch and attachment style modulate pain: a laser-evoked potentials study

Affective touch and cutaneous pain are two sub-modalities of interoception with contrasting affective qualities (pleasantness/unpleasantness) and social meanings (care/harm), yet their direct relationship has not been investigated. In 50 women, taking into account individual attachment styles, we assessed the role of affective touch and particularly the contribution of the C tactile (CT) system in subjective and electrophysiological responses to noxious skin stimulation, namely N1 and N2-P2 laser-evoked potentials. When pleasant, slow (versus fast) velocity touch was administered to the (non-CT-containing) palm of the hand, higher attachment anxiety predicted increased subjective pain ratings, in the same direction as changes in N2 amplitude. By contrast, when pleasant touch was administered to CT-containing skin of the arm, higher attachment anxiety predicted attenuated N1 and N2 amplitudes. Higher attachment avoidance predicted opposite results. Thus, CT-based affective touch can modulate pain in early and late processing stages (N1 and N2 components), with the direction of effects depending on attachment style. Affective touch not involving the CT system seems to affect predominately the conscious perception of pain, possibly reflecting socio-cognitive factors further up the neurocognitive hierarchy. Affective touch may thus convey information about available social resources and gate pain responses depending on individual expectations of social support.

This article is part of the themed issue ‘Interoception beyond homeostasis: affect, cognition and mental health’.

Attachment security and pain--The disrupting effect of captivity and PTSS

The present study assesses the possible disruption effect of posttraumatic stress symptoms (PTSS) with regard to the protective role of attachment on pain, among ex-POWs. While secure attachment seems to serve as a buffer, decreasing the perception of pain, this function may be disrupted by PTSS. The study sample included 104 subjects who were combat veterans of the 1973 Yom Kippur War comprising of 60 male ex-prisoners of war (ex-POWs) and 44 comparable male combat veterans. Both attachment and pain were investigated experimentally in the laboratory and via questionnaires. We found that ex-POWs showed higher levels of clinical pain and attachment insecurities compared to controls. Moreover, attachment avoidance and soothing effect of attachment (SEA) were both associated with lower levels of clinical pain. Most importantly, PTSS moderated the associations between attachment and pain, as well as the mediation role of attachment between captivity and pain. The results imply that although attachment can be an important resource for coping with pain, it can be severely disrupted by PTSS among trauma survivors.

Attachment insecurity predicts responses to an interdisciplinary chronic pain rehabilitation program

The aim of this study was to examine the hypothesis that attachment insecurity is associated with poorer responses to interdisciplinary treatment for chronic pain. Patients (n = 235) admitted to a 4-week interdisciplinary rehabilitation program were recruited. At pre-treatment, participants completed a battery of questionnaires assessing adult attachment styles and dimensions, as well as pain intensity, disability, self-efficacy, pain catastrophizing, and depressive symptoms. The latter measures were completed again at post-treatment. Nearly two-thirds of participants (65.5 %) reported having an insecure attachment style. Attachment insecurity was unrelated to pre- and post-treatment reports of pain intensity and pain-related disability, but was significantly associated with most other clinical variables at both time points. Regression analyses controlling for pre-treatment functioning indicated that attachment insecurity was associated with less improvement in pain catastrophizing, pain self-efficacy, and depressive symptoms. Further research is warranted to investigate the processes by which attachment characteristics influence patients' responses to chronic pain rehabilitation.

Attachment style moderates partner presence effects on pain: a laser-evoked potentials study

Social support is crucial for psychological and physical well-being. Yet, in experimental and clinical pain research, the presence of others has been found to both attenuate and intensify pain. To investigate the factors underlying these mixed effects, we administered noxious laser stimuli to 39 healthy women while their romantic partner was present or absent, and measured pain ratings and laser-evoked potentials (LEPs) to assess the effects of partner presence on subjective pain experience and underlying neural processes. Further, we examined whether individual differences in adult attachment style (AAS), alone or in interaction with the partner’s level of attentional focus (manipulated to be either on or away from the participant) might modulate these effects. We found that the effects of partner presence vs absence on pain-related measures depended on AAS but not partner attentional focus. The higher participants’ attachment avoidance, the higher pain ratings and N2 and P2 local peak amplitudes were in the presence compared with the absence of the romantic partner. As LEPs are thought to reflect activity relating to the salience of events, our data suggest that partner presence may influence the perceived salience of events threatening the body, particularly in individuals who tend to mistrust others.

I like it when my partner holds my hand: development of the Responses and Attitudes to Support during Pain questionnaire (RASP)

Social support can have beneficial effects on psychological and physiological well-being. During acute bodily pain, however, the effects of social support on pain are mixed. This variability may be due to the multifaceted nature of both pain and social support, as well as individual differences. In this paper, we present the development, psychometric assessment, and initial validation of the first self-report measure designed to address this variability in the general population; the Responses and Attitudes to Support during Pain questionnaire (RASP). The RASP includes questions on social support from the romantic partner as well as healthcare professionals (HCPs) and addresses different types of social support and pain responses. The development and validation of the RASP comprised four studies. In Study 1, a preliminary RASP version was completed by 179 healthy individuals regarding any type of acute pain. In Study 2, the reduced RASP was completed by 256 women with experiences of menstrual pain. Principal component analysis indicated a 22-item solution with five underlying dimensions reflecting General Partner Support, Emotional Support from HCPs, Anxiety in the Context of HCPs, Pain Behaviors during Partner Support, and Distraction by the Partner. Construct validity was assessed using a measure of adult attachment style. The RASP showed good validity and test-retest reliability. In Study 3, the 5-factor model received initial support through confirmatory factor analysis in a new sample of 120 individuals with recent musculoskeletal pain. Study 4 provided additional validation of the RASP in a sample of 180 individuals responding in reference to acute back pain. Overall, the RASP is a valid and reliable measure for assessing individual differences in attitudes and responses to social support in relation to acute pain.

The role of maternal attachment in the experience of labor pain: a prospective study

OBJECTIVE

To examine the influence of attachment dimensions and sociodemographic and physical predictors in the experience of labor pain.

METHODS

Eighty-one pregnant women were assessed during their third trimester of pregnancy and during labor. The perceived intensity of pain in the early stages of labor (3 cm of cervical dilatation) and before the administration of patient-controlled epidural analgesia was measured using a visual analog scale. Pain was also assessed indirectly based on anesthetic doses. Attachment was assessed using the Adult Attachment Scale-Revised.

RESULTS

Attachment anxiety and avoidance were positively and significantly correlated with labor pain and anesthetic consumption. In the multivariate models, attachment anxiety was a significant predictor of higher pain at 3 cm of cervical dilatation (β = 0.36, p = .042) and before the administration of patient-controlled epidural analgesia (β = 0.51, p = .002). Older age (β = 0.31, p = .005), a shorter duration of labor (β= -0.41, p = .001), and attachment avoidance (β = 0.41, p = .004) were significant predictors of higher anesthetic use.

CONCLUSIONS

The study findings suggest that perceived labor pain and anesthetic use are strongly associated with attachment, rather than demographic and physical factors. These data support the importance of understanding the experience of labor pain within an attachment theoretical framework.

The influence of women's attachment style on the chronobiology of labour pain, analgesic consumption and pharmacological effect

Circadian variation in biological rhythms has been identified as affecting both labour pain and the pharmacological properties of analgesics. In the context of pain, there is also a growing body of evidence suggesting the importance of adult attachment. The purpose of this study was to examine whether labour pain, analgesic consumption and pharmacological effect are significantly affected by the time of day and to analyse whether this circadian variation is influenced by women's attachment style. This prospective observational study included a sample of 81 pregnant women receiving patient-controlled epidural analgesia (PCEA). Attachment was assessed with the Adult Attachment Scale - Revised. The perceived intensity of labour pain in the early stage of labour (3 cm of cervical dilatation and before the administration of PCEA) was measured using a visual analogue scale (VAS). Pain was also indirectly assessed by measuring the consumption of anaesthetics. The latency period and the duration of effect were recorded for a chronopharmacology characterisation. Pain, as assessed with the VAS, was significantly higher in the night-time group than in the daytime group. An insecure attachment style was significantly associated with greater labour pain at 3 cm of cervical dilatation (p < 0.001) and before the beginning of analgesia (p < 0.001) as well as with higher analgesic consumption and lower pharmacological efficacy (p < 0.05). The time of day was significantly associated with the pharmacological effect: the latency period was longer at night, and the duration of the pharmacological effect was longer during the daytime. The interaction between time of day and attachment style was not significant for any of the study variables. Our results provide evidence of the importance of circadian variation in studying labour pain and the pharmacological effect of labour analgesia involving epidural blockage with a PCEA regimen. Moreover, although there was no evidence that attachment style influenced the circadian variation, these data emphasise that insecure attachment patterns are a risk factor for greater labour pain and analgesic consumption, which should be considered in pain management approaches.

Attachment styles in children affected by migraine without aura

BACKGROUND

In recent years, great attention has been given to the presence of psychological problems and psychiatric comorbidity that are also present in children affected by primary headaches. The relationship between pain and attachment has been identified, and it may be that pain perception may change in relation with specific attachment styles. The aim of the present study was to assess the prevalent attachment style and verify its putative relationship and correlation with the main characteristics of migraine attacks, in school-aged children affected by migraine without aura (MoA).

MATERIALS AND METHODS

The study population consisted of 219 children (103 males, 116 females) aged between 6 and 11 years (mean 8.96 ± 2.14 years), consecutively referred for MoA compared with 381 healthy controls (174 males, 207 females; mean age 9.01 ± 1.75 years) randomly selected from schools. All the children were classified according to the attachment typologies of the Italian modified version of the Separation Anxiety Test; monthly headache frequency and mean headache duration were assessed from daily headache diaries kept by all the children. Headache intensity was assessed on a visual analog scale. The chi-square test and t-test, where appropriate, were applied, and the Spearman rank correlation test was applied to explore the relationship between the types of attachment style and clinical aspects of MoA.

RESULTS

The MoA group showed a significantly higher prevalence of type A (avoidant) attachment (P<0.001) and a significantly lower prevalence of type B (secure) attachment (P<0.001) compared with the control group. Moreover, the Spearman rank correlation analysis showed a significant relationship between MoA characteristics and the attachment style of MoA children.

CONCLUSION

The main findings of the present study were the higher prevalence among MoA children of the avoidant attachment style (type A) and the significantly lower prevalence of the secure style attachment (type B) compared with the normal controls, suggesting that the study of psychiatric comorbidity in pediatric headache may be enriched by this new aspect of analysis.