A review of the evidence linking adult attachment theory and chronic pain: presenting a conceptual model

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.

Verbal Support From a Stranger Reduces the Development of Mechanical Hypersensitivity: Behavioral and Neurophysiological Evidence

Hand-holding reduces experimentally induced acute pain and buffers against the development of mechanical secondary hypersensitivity, an indirect proxy of central sensitization. Here, we tested if verbal support from a stranger, a common occurrence in clinical contexts, exerts the same effects. In this preregistered study, 44 healthy female participants were assigned to an alone or support group whereby a supportive female stranger encouraged them through the painful procedure leading to secondary mechanical hypersensitivity. Mechanical hypersensitivity was measured via self-reports and by the size of the anteroposterior and mediolateral spread of mechanical hypersensitivity. We investigated the moderating role of attachment style on self-reports and the effects of support on skin conductance level, salivary cortisol, and pinprick-evoked potentials. We also tested whether theta/beta ratio in the resting-state electroencephalogram predicted mechanical hypersensitivity. Self-reported ratings and the late part of the pinprick-evoked potentials were reduced in the support group, but the spread of mechanical hypersensitivity was not. Attachment anxiety and avoidance moderated the self-reported intensity such that individuals with higher attachment anxiety and avoidance scores reported lower intensity ratings in the support group. No significant effect of the verbal support was observed on skin conductance level and salivary cortisol. The theta/beta ratio did not predict the extent of hypersensitivity. Our data indicate that, in women, verbal support during intense pain leading to hypersensitivity is effective on some behavioral outcomes, but altogether the lack of group differences in cortisol, self-reported stress, and skin conductance does not provide strong support for the stress-buffering hypothesis. PERSPECTIVE: Verbal support by a stranger during a painful procedure leading to secondary mechanical hypersensitivity attenuated the development of some measures of mechanical hypersensitivity and associated neural responses in healthy female participants. No evidence was found for the role of stress. DATA AVAILABILITY: The authors will make all data available upon request.

Associations Between Adult Attachment, Pain Catastrophizing, Psychological Inflexibility and Disability in Adults with Chronic Pain

We investigated whether attachment insecurity (anxiety and avoidance) moderated the association between satisfaction with social support and pain disability. We also tested whether the relationship between insecure attachment and pain disability was serially mediated by pain catastrophising and psychological inflexibility. A large-scale cross-sectional correlational design was employed. Data were collected using an online survey. Correlation, serial mediation and moderated regression analyses were used. Data from 894 people with self-reported chronic pain were analysed. Based on correlations, age, depression, and pain intensity were included as covariates. No direct effect of satisfaction with social support on pain disability was observed in the moderation. Attachment anxiety was positively associated with pain disability (b = 1.20, t = 2.03, p < .05), but attachment avoidance was not (b = -0.08, t = -0.13, p = .90). The association between attachment anxiety and pain disability was partially mediated by pain catastrophising and psychological inflexibility (c = 1.21, t = 4.37, p < .001; a1db2 = 0.33, t = 5.15, p < .001). The relationship between attachment avoidance and pain disability was fully mediated by pain catastrophising and psychological inflexibility (c = 0.15, t = 0.54, p = .59; a1db2 = 0.13, t = 2.24, p < .05). This study provided initial evidence that pain catastrophising and psychological inflexibility mediate the association between insecure attachment and pain disability. Follow-up research using a longitudinal design is recommended.

Insecure Attachment, Oxytocinergic System and C-Tactile Fibers: An Integrative and Translational Pathophysiological Model of Fibromyalgia and Central Sensitivity Syndromes

Although the pathophysiology of fibromyalgia syndrome has been better understood in recent decades, a unified model of its pathogenesis and an effective therapeutic approach are still far from being realized. The main aim of this article will be to delve into the fundamental mechanisms of the pathophysiology of fibromyalgia conceptualized as stress intolerance syndrome. Using the biopsychosocial model of chronic pain syndromes, we will describe the potential role of the attachment system, C-tactile fibers, and oxytocinergic system dysfunction in the pathophysiology of fibromyalgia syndrome and other central sensitivity syndromes. At the end of the article, the therapeutic implications of this new global and translational pathophysiological model will be briefly discussed.

Integrating intra- and interpersonal perspectives on chronic low back pain: the role of emotion regulation and attachment insecurity

Objective

Chronic low back pain (CLBP) is burdensome and interferes with psychological and physical functioning of those affected. Past research has examined interpersonal (e.g., attachment insecurity) or intrapersonal factors (e.g., emotion regulation [ER]) involved in chronic pain. However, to enhance our understanding of CLBP's biopsychosocial underpinnings, more empirical integration of both intra- and interpersonal factors involved in CLBP is needed. Thus, our study examined the independent and joint associations of insecure attachment dimensions and ER strategies with CLBP severity and interference.

Methods

We recruited 242 US adults with CLBP through Prolific Academic, an online participant pool. Participants from Prolific Academic were eligible for the study if they were at least 18 years of age, resided in the US, reported CLBP at least half the days over the past 6 months (>3 months), and used prescribed pain medication for their CLBP. Data collection was between November 2021 and February 2022. Eligible participants filled out a Qualtrics survey which consisted of measures assessing insecure attachment dimensions, ER strategies, as well as demographical information. Outcome variables in the present study were CLBP severity and interference. We ran multiple linear regression models to examine the associations between ER strategies and insecure attachment dimensions as predictors, and CLBP severity or interference as predicted variables, after controlling for sex as a covariate; we also conducted moderation analyses to investigate the interactions between ER strategies and insecure attachment dimensions when testing associations with CLBP severity or interference.

Results

Our results indicated that, after controlling for ER strategies, anxious attachment was positively associated with CLBP interference but not pain severity (CI: 0.101 to 0.569; CI: -0.149 to 0.186); avoidant attachment was not associated with CLBP interference or severity (CI: -0.047 to 0.511; CI: -0.143 to 0.256). After adjusting for anxious and avoidant attachment, emotional expression and expressive suppression were positively associated with CLBP severity (CI: 0.037 to 0.328; CI: 0.028 to 0.421) but not interference (CI: -0.003 to 0.403; CI: -0.406 to 0.143). Furthermore, emotional expression was associated with CLBP severity and interference at low and medium levels of avoidant attachment (CI: 0.165 to 0.682; CI: 0.098 to 0.455); expressive suppression and cognitive reappraisal did not interact with attachment dimensions when examining CLBP severity or interference (CIs: LLs ≤ -0.291 to ULs ≥ 0.030).

Conclusion

Our study shows that anxious attachment may be an interpersonal risk factor related to CLBP, above and beyond intrapersonal ERs, as anxious attachment was associated with higher levels of pain interference. Furthermore, emotional expression was associated with increased CLBP severity and interference, particularly among individuals at low and medium levels of avoidant attachment. Existing studies on chronic pain have mostly focused on examining intrapersonal or interpersonal correlates in isolation. The present study extends our understanding of CLBP by considering the role of interpersonal factors (i.e., insecure attachment dimensions), in combination with intrapersonal ER strategies. Given the correlational nature of the present study, longitudinal studies are needed to establish causality between psychosocial correlates and CLBP symptoms. Ultimately, we hope our integrated approach will facilitate the development of treatments and interventions tailored to address patients' attachment-related needs, enhancing the management and maintenance of CLBP among patients.

Pharmacogenetic Approaches in Personalized Medicine for Postoperative Pain Management

Despite technical and pharmacological advancements in recent years, including optimized therapies and personalized medicine, postoperative pain management remains challenging and sometimes undertreated. This review aims to summarize and update how genotype-guided therapeutics within personalized medicine can enhance postoperative pain management. Several studies in the area have demonstrated that genotype-guided therapy has the ability to lower opioid consumption and improve postoperative pain. Gene mutations, primarily OPRM1, CYP2D6, CYP2C9, COMT and ABCB1, have been shown to exert nuanced influences on analgesic response and related pharmacological outcomes. This review underscores the integration of pharmacogenetic-guided personalized medicine into perioperative care, particularly when there is uncertainty regarding opioid prescriptions. This approach leads to superior outcomes in terms of postoperative pain relief and reduced morbidity for numerous patients.

Attachment Anxiety and Dissociation Mediate Associations Between Polytrauma and Somatization in Kenyan Adolescents

The experience of several potentially traumatic events (PTE) is a risk factor for higher somatization symptoms severity among adolescents. Attachment orientations and dissociation may influence the link between exposure to PTE and somatization symptoms severity. We analyzed the associations between direct exposure to PTE and somatization symptoms in Kenyan adolescents and explored the mediating role of attachment orientations and dissociation symptoms in the associations between direct exposure to PTE with somatization symptoms severity. A sample of 475 Kenyan adolescents completed validated self-report questionnaires. Serial multiple mediation models were tested by conducting a structural equation modeling employing Preacher and Hayes' procedures (2008). Attachment anxiety and dissociation symptoms mediate the association between direct exposure to traumatic events and somatization symptoms. Higher exposure to traumatic events was significantly associated with higher attachment anxiety levels, which was associated with higher levels of dissociation symptoms, which was then associated with higher somatization symptoms severity. High levels of attachment anxiety and dissociation might aggravate somatization symptoms differently according to sex, which might be seen as a psychological distress mechanism subsequent to exposure to multiple PTE in African adolescents.

Associations between participation and personal factors in community-dwelling adults post-stroke

PURPOSE

To examine associations between post-stroke participation and personal factors, including demographic characteristics, self- and threat appraisals, and personality variables.

METHODS

An exploratory cross-sectional study with purpose-designed survey was completed online or via mail. The survey was comprised of demographic and health-related questions and multiple questionnaires, including the Stroke Impact Scale Version 3.0 (SISv3) (participation/perceived recovery), Community Integration Questionnaire (CIQ) (participation), Head Injury Semantic Differential III (pre- vs post-stroke self-concept/self-discrepancy), Appraisal of Threat and Avoidance Questionnaire (threat appraisal), Life Orientation Test - Revised (optimism) and Relationships Questionnaire (adult attachment style) that measured variables of interest. Sixty-two participants, aged 24-96 years who had experienced a stroke (one or multiple events) and had returned to community living, completed the survey. Associations were examined using correlations, and univariate and multiple linear regression analyses.

RESULTS

Regression analysis showed that greater participation, measured using the CIQ, was associated with younger age, female gender, lower self-discrepancy and higher perceived recovery, explaining 69% of the variability in CIQ participation. Further, greater participation on the SISv3 was associated with lower self-discrepancy and higher perceived recovery, explaining 64% of the variability in SISv3 participation.

CONCLUSIONS

Results indicate that personal factors, particularly self-appraisals like self-concept/self-discrepancy, in combination with perceived recovery may be important in explaining a large portion of variance in post-stroke participation. Specifically, findings highlight the interrelatedness of self-concept change, perceived recovery and post-stroke participation. Further longitudinal research is needed to clarify the directionality of these associations throughout the hospital-to-home transition.

The impact of the social context on the development of secondary hyperalgesia: an experimental study

ABSTRACT

Social support has been shown to reduce pain ratings and physiological responses to acute pain stimuli. Furthermore, this relationship is moderated by adult attachment styles. However, these effects have not been characterized in experimentally induced symptoms of chronic pain, such as secondary hyperalgesia (SH) which is characterized by an increased sensitivity of the skin surrounding an injury. We aimed to examine whether social support by handholding from a romantic partner can attenuate the development of experimentally induced SH. Thirty-seven women, along with their partners, participated in 2 experimental sessions 1 week apart. In both sessions, SH was induced using an electrical stimulation protocol. In the support condition, the partner was seated across from the participant holding the participant's hand during the electrical stimulation, whereas in the alone condition, the participant went through the stimulation alone. Heart rate variability was measured for both the participant as well as the partner before, during, and after the stimulation. We found that the width of the area of hyperalgesia was significantly smaller in the support condition. Attachment styles did not moderate this effect of social support on the area width. Increasing attachment avoidance was associated with both a smaller width of hyperalgesia and a smaller increase in the sensitivity on the stimulated arm. For the first time, we show that social support can attenuate the development of secondary hyperalgesia and that attachment avoidance may be associated with an attenuated development of secondary hyperalgesia.

Are We Any Closer to Understanding How Chronic Pain Develops? A Systematic Search and Critical Narrative Review of Existing Chronic Pain Vulnerability Models

Identifying biopsychosocial factors underlying chronic pain vulnerability is essential for the design of preventative efforts. Multiple chronic pain vulnerability models exist, however, there is a lack of comprehensive evaluation of these models in the literature, potentially due to the lack of guidelines that specify the criteria by which these types of work should be assessed. In this work, we created evaluation criteria (based on the general goals of conceptual models), and we then used them to critically review the chronic pain vulnerability models available in the current peer-reviewed literature (identified through a systematic search). Particularly, we evaluated the models on the basis of conceptual clarity/specificity of measures, depth of description of aetiological and mechanistic factors, use of a whole system approach, and quality of the evidence associated with the models. We found nine conceptual models that have been explored in detail (eg, fear avoidance model, diathesis-stress model). These models excel at clarity and are supported mostly by self-report evidence of a psychological nature (anxiety sensitivity, pain catastrophizing, etc.), but provide little explanation of mechanistic and aetiological factors. In the future, models could be improved by complementing them with proposals from other models and exploring potential causal factors and mechanisms maintaining the condition. This task could be carried out through prospective cohort studies, and computational approaches, amongst others.

Neurophysiological and Psychosocial Mechanisms of Fibromyalgia: A Comprehensive Review and Call for An Integrative Model

Research into the neurobiological and psychosocial mechanisms involved in fibromyalgia has progressed remarkably in recent years. Despite this, current accounts of fibromyalgia fail to capture the complex, dynamic, and mutual crosstalk between neurophysiological and psychosocial domains. We conducted a comprehensive review of the existing literature in order to: a) synthesize current knowledge on fibromyalgia; b) explore and highlight multi-level links and pathways between different systems; and c) build bridges connecting disparate perspectives. An extensive panel of international experts in neurophysiological and psychosocial aspects of fibromyalgia discussed the collected evidence and progressively refined and conceptualized its interpretation. This work constitutes an essential step towards the development of a model capable of integrating the main factors implicated in fibromyalgia into a single, unified construct which appears indispensable to foster the understanding, assessment, and intervention for fibromyalgia.

Evaluation of the Danish version of the prenatal parental reflective functioning questionnaire in early pregnancy as a screening tool

Parental reflective functioning (PRF) is the capacity to focus on feelings and experiences in oneself as a parent and in the child. Research has demonstrated that, the better the PRF the better outcomes for the child. This paper evaluated the Danish version of the prenatal parental reflective functioning questionnaire (P-PRFQ). We used data from a cluster-randomized trial of pregnant women recruited from Danish general practice. The sample included 605 mothers. Factor structure and internal consistency were investigated. Linear regression analysis was used to examine the associations between the P-PRFQ score and the five most predictive variables. The confirmatory factor analyses supported the three-factor model. The P-PRFQ had moderate internal consistency. The regression analysis showed a decrease in the P-PRFQ score with increasing age, increasing parity, current employment, better self-reported health, lower anxiety score, and fewer negative life events with persistent impact. The directions of the associations between P-PRFQ score and the predictive variables were opposite of what was hypothesized raising questions about whether the P-PRFQ can be used as an early pregnancy screening tool assessing prenatal PRF. Further validation studies are required to assess the extent to which the P-PRFQ truly measures reflective functioning.

Health-related quality of life of women with endometriosis: An Attachment-Diathesis Model of Chronic Pain perspective

Endometriosis is a common gynecological disorder that occurs in women of reproductive age, and negatively affects women's quality of life. We tested 'Attachment-Diathesis Model of Chronic Pain' in a sample of Turkish women with endometriosis by analyzing the paths among attachment styles, pain catastrophizing, coping strategies, and health-related quality of life (HRQoL). Attachment anxiety was related to using less problem-focused coping and seeking more social support, while attachment avoidance was associated with seeking less social support as a coping strategy. Moreover, attachment anxiety and higher pain catastrophizing were related to a worse HRQoL. Finally, problem-focused coping strategy mediated the relation between attachment anxiety and HRQoL, meaning that by employing less problem-focused coping strategies, anxiously attached women experienced a poorer HRQoL. In light of our findings, psychologists may develop intervention techniques that question attachment patterns, pain perception, and coping strategies in clients diagnosed with endometriosis.

Psychological and cultural factors influencing antibiotic prescription

Humans have inundated the environment worldwide with antimicrobials for about one century, giving selective advantage to antibiotic-resistant bacteria. Therefore, antibiotic resistance has become a public health problem responsible for increased mortality and extended hospital stays because the efficacy of antibiotics has diminished. Hospitals and other clinical settings have implemented stewardship measures to reduce antibiotic administration and prescription. However, these measures demand multifactorial approaches, including multidisciplinary teams in clinical settings and the education of professionals and patients. Recent studies indicate that individual factors, such as mother-infant attachment and parenting styles, play a critical role in antibiotic use. Also, macrocontextual factors, such as economic, social, or cultural backgrounds, may impact antibiotic use rates. Therefore, research aiming to ameliorate stewardship measures must include psychologically and sociologically based research.

Injury, illness, and emotion: A review of the motivational continuum from trauma through recovery from an ecological perspective

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Attachment and Clinical Outcomes Among Treatment-Seeking Adults With Persistent Symptoms After Mild Traumatic Brain Injury

OBJECTIVE

Interpersonal attachment influences the development and course of disease. Overreliance on insecure attachment strategies may increase risk for poor disease outcomes. This study aimed to investigate largely unexplored relationships between attachment strategies and clinical outcomes among adults with persistent symptoms after mild traumatic brain injury (mTBI).

METHODS

Participants with persistent symptoms after mTBI (N=83) completed measures assessing dimensions of insecure attachment (Relationship Scales Questionnaire [RSQ]), persistent symptoms (Rivermead Post-Concussion Symptoms Questionnaire), depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), and health-related quality of life (HRQOL) (Quality of Life After Brain Injury-Overall Scale). Questionnaires were administered at clinic intake (mean=18.1 weeks postinjury) and again 3-4 months later (mean=32.2 weeks postinjury), except the RSQ, which was administered only in the follow-up assessment. Treatment response for each outcome was calculated as the difference between scores at clinic intake and follow-up. Generalized linear models were fitted for each clinical outcome, with RSQ variables as predictors.

RESULTS

Higher attachment anxiety was associated with greater persistent symptom severity, greater depression and anxiety symptoms, and worse HRQOL at follow-up. Higher attachment anxiety was also associated with less improvement in depression and HRQOL over time. In contrast, attachment avoidance was unrelated to any of the clinical outcomes.

CONCLUSIONS

Attachment anxiety, the fear that a significant other will not be available in stressful circumstances, may be a particularly important social factor associated with health among adults with persistent symptoms after mTBI. Greater consideration of the attachment system is warranted in mTBI care and research.

Attachment Style and Burn Pain

Pain management is a challenge when treating patients with burn injuries. Understanding the behavioral and interpersonal aspects of the experience of burn pain may aid in its management. Attachment style-which influences how an individual relates to other people-is one aspect that may affect the experience of burn pain. Past research has shown a relationship between an individual's attachment style and certain types of pain and disorders. The study builds upon that past work to investigate specifically how attachment style affects the experience of acute burn pain. Participants were at least 18 years old and admitted to an American Burn Association verified burn center with burns encompassing 30% or less total body surface area. Participants completed demographic questionnaires and a standardized measure of adult attachment style. Data regarding use of analgesics, daily pain scores, and burn-related information were collected through medical chart review. Participants who reported a secure attachment style required less pain medication and reported less pain compared with participants who reported an insecure attachment style. There was no difference in burn-related variables between participants with secure and insecure attachment styles, suggesting that these differences were not due to burn-related factors. Attachment, therefore, may play a role in an individual's perception of acute burn pain, which impacts analgesic requirements needed to manage the pain. These results have potential implications for the use of psychosocial interventions to reduce the experience of pain and the amount of pain medication needed to manage acute burn pain.

Living with Chronic Pain During the COVID-19 Pandemic: A Qualitative Analysis

Purpose

COVID-19 pandemic containment measures have led to changes in various areas of life, including restrictions on health care. Patients with chronic pain may have faced an increased burden during pandemic and the resources of this vulnerable population are unknown. Therefore, a qualitative study was conducted to understand how people with chronic pain have experienced the course of the pandemic.

Patients and Methods

Twenty semi-structured telephone interviews were conducted six months after the initial lockdown in Germany. The participants were patients with chronic pain who exhibited varying changes in their pain during the first German lockdown, recruited from a German outpatient pain clinic at a Department of Anesthesiology and Intensive Care. The semi-structured interview guidelines were designed to explore how patients with chronic pain experienced their pain during the pandemic, how they coped, and how they experienced pain management during this time. The interview recordings were transcribed verbatim and coded using the qualitative content analysis method.

Results

Four themes emerged from the results: differential impact on pain experience, difficulty coping with pain, supportive pain management, and endurance.

Conclusion

During this uncertain time, it was particularly important to maintain pain treatment in order to establish a sense of safety and stability. This underscores the special role of maintaining therapeutic contact during a pandemic and the potentially special role of telemedicine.

Rehabilitation of post-COVID patients with chronic fatigue and cognitive disorders syndromes

Almost all patients, who have experienced acute manifestations of COVID-19, regardless of the severity of the acute phase of the disease, are only at the beginning of a long way to recovery. According to experts, SARS-CoV-2 infection should affect almost 80% of the world's population, so all these patients to a greater or lesser extent will need a rehabilitation of certain manifesta-tions of postcovid syndrome. Purpose: to study the effectiveness of rehabilitation program and the dynamics of cognitive im-pairment and manifestations of chronic fatigue syndrome in patients after coronavirus disease. Methods: The study design included 60 patients after SARS-Cov-2 infection. Among the exam-ined patients there were 26 (43,3%) women and 34 (56,7%) men. An average age of the patients was 43,9±1,08 years. Patients were referred to the Department of Physical Rehabilitation after coronavirus disease with chronic fatigue and cognitive disorders syndromes. Accordingly, all patients, who participated in the study, were divided into two groups: group I - 28 patients with a general condition of moderate severity at the hospital stage and 32 patients - group II, with se-vere course of the disease and oxygen demand at the hospital stage. Depending on the duration of rehabilitation, two observation periods were used - on the 7th and 14th day of rehabilitation program. Results: It has been proven, that patients, who didn’t need oxygen, were complaining about an-osmia, cephalgia, cognitive impairment, increased anxiety and fatigue. Dysgeusia, dyssomnia, and depression were more common in patients, requiring oxygen therapy at the hospital stage. Rehabilitation program eliminated cognitive dysfunction, depression, cephalgia, drowsiness and dyssomnia on the 7th day in patients, who did not require oxygen therapy (p>0,05), and in patients, who needed oxygen therapy - on the 14th day of the rehabilitation program (p>0,05). However, 2 (6,3%) and 3 (9,4%) patients, who needed oxygen therapy, even after 14 days of reha-bilitation had manifestations of minor recurrent headache and drowsiness. Conclusion: Thus, patients after coronavirus disease, who needed oxygen therapy at the hospital stage, need long-term rehabilitation program. Keywords: postcovid syndrome, anxiety, depression, drowsiness, rehabilitation

Individual treatment goals and factors influencing goal attainment in patients with somatic symptom disorder from the perspective of clinicians: A concept mapping study

OBJECTIVE

Overviews of treatment goals and influencing factors may support shared decision making and optimize customized treatment to the patient with somatic symptom disorder (SSD). The aim of this study was to identify and structure comprehensive sets of treatment goals and factors influencing goal attainment in patients with SSD from the perspective of clinicians.

METHODS

Using a concept mapping procedure, clinicians participated in interviews (N = 17) and card sorting tasks comprising 55 treatment goals and 55 factors influencing goal attainment (N = 38).

RESULTS

We identified four overarching categories (A to D) of nine clusters (1 to 9) of treatment goals: A. empowerment (A1. personal values, A2. committed action, A3. self-esteem), B. skill improvement (B4. interpersonal skills, B5. emotion and stress regulation), C. symptom reduction (C6. dysfunctional beliefs, C7. somatic symptoms, C8. psychological symptoms), and D9. active and structured lifestyle. Also, we identified four overarching categories (A to D) of nine clusters (1 to 9) of factors influencing goal attainment: A1. therapeutic alliance, B. social and everyday context (B2. [family] system, B3. meaningful daily schedule, B4. social and economic circumstances), C. ability to change (C5. externalizing tendency, C6. reflective and psychological skills, C7. perspective and motivation), and D. psychological vulnerability (D8. vulnerable personality, D9. [psychiatric] comorbidity).

CONCLUSION

The overviews of treatment goals and factors influencing goal attainment reflect different paradigmatic backgrounds of clinicians. The results can be used, in combination with the perspective of the patient, to define treatment goals, and to monitor and evaluate change in outcomes.

Integrated neuroimmune processing of threat, injury, and illness: An ecological framework mapping social alienation onto lifetime health vulnerability

Social alienation is a pre-eminent ecological threat for humans. In clinical and social care settings its impact is acknowledged in conditions as diverse as severe mood disturbance, chronic pain, and metabolic non-communicable diseases. An integrated psychoneuroimmune perspective shows how threat, injury, healing, and recovery follow through as a continuous process, but accepted cultural and clinical paradigms separating mental from physical illness provide little common ground on which to analyse and apply this continuum in practice. By reviewing the ecological relationships between emotional threat, tissue dyshomeostasis and injury, infection, pain, and mood this article explores not only how primeval somatic responses underpin the evolutionary foundations of depression and somatisation, but also links them to escalating physical non-communicable disease through archived socioeconomic adversity (allostatic load). Social alienation (in the absence of trauma) may prime and activate this ancient repertoire in which sensitised responses lay the foundation for persistent maladaptive states of aversive sensory misinterpretation, behavioural avoidance, anhedonia, and neuroinflammation presenting as widespread non-nociceptive pain, non-pain somatisation, and severe depression. The ecological perspective illuminates perverse clinical presentations, shows how some approaches to care may facilitate self-reinforcement in maladaptive syndromes, and offers pointers for inclusive rehabilitative clinical and social care.

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 and symptom reporting in adolescents and young adults after a concussion

BACKGROUND

The incidence of hospital-treated concussion is 100-300/100,000 person years. Reporting of long-lasting post-concussion symptoms (PCS) is estimated at 5-15%. Attachment insecurity is a potential vulnerability factor for physical illness and poorer disease outcomes in general. This study aimed to explore associations between attachment insecurity and PCS in young people sustaining a concussion.

METHODS

This cross-sectional study was embedded in a cohort of 15-30-year-old patients (n = 3080) 3 months after sustaining a concussion. Data were obtained from a database and questionnaires. PCS were measured by the Rivermead Post-Concussion Symptoms Questionnaire and attachment dimensions (anxiety and avoidance) by the Experiences in Close Relationships-Relationship Structures Questionnaire. Multiple linear regression models were performed to investigate the association between the attachment dimensions and PCS with adjustment for demographic, injury-related and psychological factors and with additional testing for interaction between the attachment dimensions.

RESULTS

In the final study sample, comprising 973 patients (31.6%), we found an interaction between the attachment dimensions. Hence, the effect of attachment anxiety on PCS was statistically insignificant at low avoidance (25th percentile) but significant at high avoidance (75th percentile, β = 0.64 (95%CI: 0.02; 1.26)), whereas the effect of attachment avoidance was significant regardless of level of attachment anxiety (25th percentile, β = 1.09 (95%CI: 0.18; 2.01); 75th percentile, β = 2.71 (95%CI: 1.80; 3.61)).

CONCLUSION

Attachment insecurity, especially characterised by high avoidance in combination with high anxiety, also called fearful attachment, is associated with PCS. Considering the attachment perspective can potentially improve health care for this patient group.

Evaluation of Attachment Style and Social Support in Patients With Severe Migraine. Applications in Doctor-Patient Relationships and Treatment Adherence

Objectives: The aim of this observational study was to describe social support and patterns of attachment among patients with migraine. We hypothesized that in comparison to the general population, insecure attachment is overrepresented in migraine patients, and that these patients have less social support. We also aimed to study the specific relationship between attachment and social support. We hypothesized that patients with an insecure attachment style have less social support than patients with a secure attachment style.

Methods: A total of 101 consecutive patients (88.1% women) aged between 25 and 60 (average age = 41.4) were recruited at the Specialized Center for the Consultation of Primary Headaches at the Regional University Hospital Center of Besançon (France). Migraine impact and disability were evaluated using the Headache Impact Test (HIT-6) questionnaire and Migraine Disability Assessment (MIDAS) questionnaire. Patients also completed several self-administered psychological questionnaires in their validated French versions: the Medical Outcome Survey 36-Item Short-Form Health Survey, the Cungi Scale, the State-Trait Anxiety Inventory, the Beck Depression Inventory, the Relationship Scales Questionnaire and the Sarason's Social Support Questionnaire.

Results: The distribution of attachment profiles was different from that of the general population, with an overrepresentation of insecure attachment styles (p = 0.018). Our study showed that migraine patients had less social support than the general population, both in terms of the number of people providing support (p = 0.002) and the level of satisfaction concerning this social support (p = 0.000). We also found that neither the number of available persons score nor the satisfaction score were statistically different between the four attachment categories (p = 0.49). Patient's attachment style and social support influence the patient-doctor relationship, the therapeutic alliance and health behaviors such as treatment adherence.

Conclusions: Based on the data we obtained, we developed applications in patient care for people with particular attachment styles and low social support. A treatment plan adapted to the patient's attachment profile should be created to develop “precision medicine” using a personalized approach to the doctor-patient relationship. We would also recommend encouraging patients to participate in support groups, in order to strengthen their attachment systems and gain social support.

Clinical Trial Registration:https://clinicaltrials.gov/ct2/show/NCT03577548, identifier NCT03577548.

Somatoform complaints in middle childhood A developmental path-analysis

Repeatedly occurring somatoform complaints often cause disruptions in children’s daily life, both in family and school settings. Associated with these complaints, there is an increased demand for medical help in the affected children. Despite the frequent occurrence of somatoform complaints in childhood, only a small number of studies have focused on this subject, and the development and maintenance of somatoform complaints have not sufficiently explained to date. Previous research suggests that many different factors are involved, including insecure attachment, a lack of emotion regulation (ER) strategies, and psychiatric behavior problems. The aim of this study is to examine possible pathways describing the interplay of aforementioned factors, in order to contribute to a deeper understanding of the underlying mechanisms. A nonexperimental cross-sectional study was conducted. Questionnaires were completed by 221 children (female n = 115; Mage = 9.70 years, SDage = .56) reporting on their attachment and ER strategies, and their parents reported on the behavior problems and somatoform complaints. Path analysis revealed a good model fit (Χ2 = p .798, Χ2/df = .415, NFI = .994, CFI = 1.000, RMSEA = .000). Results revealed that attachment anxiety predicted maladaptive ER strategies, and attachment avoidance predicted emotion control. In turn significant paths were found between ER strategies, behavior problems, and somatoform complaints. This study provides a first insight into the underlying mechanisms describing the occurrence of somatoform complaints. Results revealed two developmental pathways, based on attachment quality and mediated through different emotion regulation strategies.

Clinical Trial Registration: The project “Impact factors and conditions of somatoform symptoms in childhood within familial and school contexts” is listed in the German Clinical Trails Register (DRKS-ID: DRKS00012444) and the WHO International Clinical Trials Registry Platform.

An Attachment Perspective on Partner Responses to Genito-pelvic Pain and Their Associations with Relationship and Sexual Outcomes

Although facilitative and negative partner responses are known to impact couples' adaptation to provoked vestibulodynia (PVD), a chronic genito-pelvic pain condition, it is still unknown what leads individuals to adopt or perceive such adaptative or detrimental behaviors. Attachment influences sexual and relationship adjustment, emotional reactivity and perceived support in romantic relationships, and as such could be associated with partner responses. This study aimed at examining the mediating role of facilitative and negative partner responses in the associations between attachment and relationship and sexual adjustment in 125 couples coping with PVD. Couples completed self-report questionnaires on attachment, partner responses, sexual satisfaction and distress, and relationship satisfaction. Results indicated that partners' attachment avoidance was negatively associated with facilitative partner-reported responses, which in turn was associated with partners' sexual and relationship satisfaction. Attachment anxiety in women and partners was associated with greater women-perceived negative partner responses, which in turn was associated with women's and partners' greater sexual distress and lower sexual satisfaction, and women's lower relationship satisfaction. Partners' greater attachment anxiety was also associated with greater partner-reported facilitative responses, which was associated with partners' lower and women's greater relationship satisfaction. Assessing attachment orientations may help clinicians better understand couples' dyadic coping.

What factors are most important for the development of the maternal-fetal relationship? A prospective study among pregnant women in Danish general practice

Background

Development of the maternal antenatal attachment (MAA) constitutes an important aspect of the transition into motherhood. Early identification of women at risk of developing a poor MAA provides possibilities for preventive interventions targeting maternal mental health and the emerging mother-infant relationship. In this study, we investigate the relative importance of an extensive set of psychosocial, pregnancy-related, and physiological factors measured in the first trimester of pregnancy for MAA measured in third trimester.

Methods

A prospective study was conducted among pregnant women in Danish general practice (GP). Data were obtained in the first and the third trimester from pregnancy health records and electronic questionnaires associated with routine GP antenatal care visits. The Maternal Antenatal Attachment Scale (MAAS) was used to assess maternal antenatal attachment. The relative importance of potential determinants of maternal antenatal attachment was assessed by the relative contribution of each factor to the fit (R²) calculated from multivariable regression models.

Results

The sample consisted of 1328 women. Low antenatal attachment (Total MAAS ≤ 75) was observed for 513 (38.6%) women. Perceived social support (having someone to talk to and having access to practical help when needed) emerged as the most important determinant. Furthermore, scores on the MAAS decreased with worse self-rated health, poor physical fitness, depression, increasing age, having given birth previously, and higher education.

Conclusion

Pregnant women reporting lack of social support and general low physical and mental well-being early in pregnancy may be at risk for developing a poor MAA. An approach targeting both psychosocial and physiological well-being may positively influence expectant mothers’ successful adaptation to motherhood.

Depressive Symptoms and Quality of Life in a Sample of Italian Women with a Diagnosis of Fibromyalgia: The Role of Attachment Styles

BACKGROUND

Women with fibromyalgia (FM) commonly suffer from depression, pervasive fatigue, and pain. The attachment style has been hypothesized to be an important factor for understanding the experience of these symptoms. Therefore, the present cross-sectional study is aimed at investigating the effect of attachment styles in women with a diagnosis of FM on depressive symptoms and quality of life.

METHOD

Participants were 453 Italian women with a physician's diagnosis of FM with a mean age of 47 years (SD = 10.9). To assess attachment styles, quality of life, and depressive symptoms, women responded, respectively, to the Relationship Questionnaire, the World Health Organization Quality of Life Questionnaire, and the Beck Depression Inventory II.

RESULTS

Our results showed that the incidence of depressive symptoms was elevated, with 59% of women reporting moderate to severe symptoms. Also, the statistical analyses showed that both preoccupied and avoidant/dismissing attachments were related with depression symptoms and low perception of QoL.

CONCLUSIONS

Our study demonstrates that, when evaluating the impact of FM on the QoL of women, it is important to consider the complexity of the variables that are at play. Insecure attachment styles and depressive symptoms seem to increase the likelihood of the psycho-social-somatic malaise in FM women.

Adult attachment styles, self-esteem, and quality of life in women with fibromyalgia

Recently, the research on pain-related disability has increasingly paid attention to the psychological and social factors that may influence the biological condition. In the current study, we aimed to explore attachment styles, self-esteem, and quality of life in individuals with a diagnosis of fibromyalgia. Participants were 371 diagnosed women, with a mean age of 42.7 years (standard deviation = 10.6). The average number of years since diagnosis was 7.4 years (standard deviation = 2.4) years. To assess attachment, quality of life, and self-esteem, women responded, respectively, to the Relationship Questionnaire, the World Health Organization Quality of Life Questionnaire, and the Rosenberg Self-Esteem Inventory. Our results showed that secure attachment relationships and high self-esteem represent protective factors for quality of life of women with fibromyalgia, while the contrary emerged for insecure attachments and low self-esteem. The understanding of the psychological components that contribute to fibromyalgia may improve the effectiveness of interventions.

Association of fear-avoidance and self-efficacy on pain disability in individuals with co-morbid post-traumatic stress and chronic pain

This study investigated relationships between post-traumatic stress symptoms (PTSS) and pain disability. Fifty people with chronic pain (probable PTSD, n = 22) completed measures assessing pain interference, PTSS, fear avoidance, and pain self-efficacy. We hypothesized that people with probable PTSD would have higher fear avoidance and lower pain self-efficacy; and that PTSS would be indirectly associated with pain disability via fear avoidance and self-efficacy. People with probable PTSD had higher fear avoidance, but there were no differences in self-efficacy, pain severity or disability. There was an indirect association between PTSS and pain disability via fear avoidance, but not via self-efficacy.

Parenting style during childhood is associated with the development of chronic pain and a patient's need for psychosomatic treatment in adulthood: A case-control study

The aim of this study is to investigate the relation between parenting style and chronic pain and the patients' need for psychosomatic treatment in adulthood.We compared 4 combinations of 2 parenting style subscales, high and low care and overprotection, among the following 4 age- and sex-matched groups: community-dwelling subjects without chronic pain (n = 100), community-dwelling subjects with chronic pain (n = 100), outpatients with chronic pain (n = 50), and inpatients with chronic pain (n = 50). Parenting style was assessed for both the mother and father by use of the Parental Bonding Instrument questionnaire. The parenting style associated with the worst outcome was defined as both low care and high overprotection, as reported in previous studies.The frequency of reported adverse parenting style was significantly higher among chronic pain patients than community-dwelling subjects without chronic pain (all P < .05). The odds ratios for an adverse parenting style significantly increased through the categories after adjusting for demographic factors and the pain visual analog scale (P for trend <.01).These findings suggest that parental low care and high overprotection during childhood contribute to the future risk of chronic pain and the patients' need for psychosomatic treatment in adulthood.

Maternal sensitivity and mother-infant attachment are associated with antibiotic uptake in infancy

Attachment security has been associated with health status and symptom reporting. In this longitudinal study, we investigated the association between antibiotics uptake by infants at 9-months and mother-infant attachment at 12-months. Logistic regression analyses indicated that lower maternal sensitivity was associated with increased odds of antibiotic uptake. Furthermore, 89.7% of insecure-ambivalent infants consumed antibiotics, which contrasted with 32.5% of avoidant infants and 21.5% of secure infants. This study suggests that maternal behavior and mother-infant attachment impact on antibiotic consumption, which is worrying because antibiotics may lead to several health problems later in life and antibiotic-resistance.

Modeling the relationship between attachment styles and somatic symptoms with the mediating role of emotional processing

INTRODUCTION

In spite of our general knowledge about psychological roots and defects of developmental processes in the formation of somatic symptoms, the effect of the interaction of developmental components with cognitive-emotional variables is unclear. Previous researches suggest that individuals with insecure attachment may have a higher risk to experience of somatic symptoms. The main aim of this study is "Modeling the Relationship between Attachment Styles and Somatic Symptoms with the Mediating Role of Emotional Processing."

MATERIALS AND METHODS

This study was a descriptive-correlational study. Two hundred and twenty individuals aged 18-59 years living in Tehran were selected by available sampling from the general population. Collins and Reed's Adult Attachment Scale, Baker's Emotional Processing Scale, and Patient Health Questionnaire were used to collecting data. Data analysis was performed by Pearson correlation and independent t-test. The conceptual model presented in this study was tested with a path analysis approach.

RESULTS

Given the Chi-squared size (χ²= 1.214; P > 0.05), it can be said that the proposed conceptual model fits well with the observed model. Besides, checking the other absolute and relative indices also shows a very good fit of the model.

CONCLUSION

Our results showed that when the reciprocal effects of attachment styles were controlled, secure attachment could be considered as a protective factor against deficits in emotional processing and somatization of negative emotions. On the other hand, we found that when the dominant attachment style in individuals was anxiety based, it could be possible that they experience deficiency in the processing of emotion and more severe somatic symptoms.

When a Head Is about to Burst: Attachment Mediates the Relationship Between Childhood Trauma and Migraine

Background: People exposed to childhood trauma show insecure attachment patterns and are more prone to chronic and pain-related conditions, including migraine. The aim of this study was to explore the mediating role of attachment in the association between childhood trauma and adulthood chronic health conditions, with a focus on migraine. Methods: Respondents from a representative sample of citizens of the Czech Republic (n = 1800, mean age: 46.6 years, 48.7% male) were asked to report various chronic and pain-related conditions, childhood trauma (The Childhood Trauma Questionnaire, CTQ), and attachment anxiety and avoidance (The Experience in Close Relationships Revised, ECR-R) in a cross-sectional, questionnaire-based survey conducted in 2016. Structural equation models (SEM) adjusted for sociodemographic variables were used to assess the relationship between childhood trauma, adulthood attachment, and adulthood chronic health conditions (migraine, other pain-related conditions, chronic health conditions other than pain, no chronic health complaints). Results: After adjusting for sociodemographic variables, SEM confirmed a significant mediation of the relationship between childhood trauma and migraine through adulthood attachment. There was no mediation effect of adulthood attachment found in other health complaints. Conclusion: This study highlights the mediation effect of attachment in the link between childhood trauma and migraine. Attachment-based therapeutic interventions can be useful in the treatment of patients with migraine.

Attachment style and parental bonding: Relationships with fibromyalgia and alexithymia

Objectives

Fibromyalgia (FM) is a chronic pain syndrome, and alexithymia, which is a condition that is characterised by deficits in emotional self-awareness, is highly prevalent among individuals with FM. Insecure attachment styles and inadequate parental care appear to play an important role in the onset and maintenance of both alexithymia and chronic pain. Therefore, the present study aimed to examine the associations between attachment styles, parental bonding, and alexithymia among patients with FM and healthy controls (HC).

Methods

All participants completed a battery of tests that assessed alexithymia, attachment styles, and parental bonding. Two logistic regression models were tested to examine whether these variables predict (a) group membership (i.e. patients with FM vs. HC) and (b) the likelihood of having alexithymia (i.e. among patients with FM and HC).

Results

Alexithymia (i.e. difficulty identifying and describing feelings subscales of the 20-item Toronto Alexithymia Scale) significantly predicted group membership (i.e. the likelihood of having FM). On the other hand, educational level and dismissive attachment (i.e. the discomfort with closeness and relationships as secondary subscales of the Attachment Style Questionnaire) were the only significant predictors of the likelihood of having alexithymia.

Conclusions

These findings highlight both the relevance of alexithymic traits to the definition of FM and centrality of an insecure attachment style to the manifestation of alexithymia.

Relationship Between Spiritual Health and Pain Self-Efficacy in patients with Chronic Pain: A Cross-Sectional Study in West of Iran

In recent years, the prevalence of chronic diseases has had a growing trend, which has resulted in many health problems. Level of belief in God is effective on people's attitudes to life concepts, social deviations and psychological disorders, and improves them. Therefore, the present research was conducted with the aim of determining the relationship between spiritual health (SH) and pain self-efficacy (PSE) in Ilam City in 2018. This study was a descriptive cross-sectional study in the group of patients with chronic pain (CP). In this study, the study population was patients with CP in Ilam City and the study sample was 150 patients with CP referring to public and private health centers in Ilam, which had all the criteria for participation in the study. The findings showed mean (SD) of the total score of SH variables was 65.16 (9.88), and PSE was 34.48 (4.08). According to Pearson statistical analysis, there is a significant relationship between SH and PSE (r = 0.442, P = 0.000). Also, the standard beta and non-standard beta coefficients for SH variables in PSE show that the non-standard beta coefficient in SH is equal to 0.183. The results of this study showed that SH is a predictor of pain acceptance, so that patients who were more religious were more likely to tolerate CP. For this reason, it is suggested that religious interventions be performed to reduce pain in patients with CP, in order to provide the necessary context for pain reduction in this group of patients.

[Diagnostics and therapy of back pain: what is advisable? What should be avoided and why is it still done?]

Diagnostic and therapeutic procedures are popular and frequently performed for low back pain. This narrative review presents and discusses the myths and evidence related to these procedures.In most cases it is nonspecific pain, for which no underlying disease can be named. Image diagnostics using X‑rays and MRI are rarely helpful in the case of new nonspecific back pain.Evidence for chirotherapy is doubtful. Also, evidence is lacking for invasive and surgical procedures in local and regional low back pain. These procedures show superiority in radicular pain only: extraction of disc herniation in acute and subacute leg pain and segmental lumbar fusion in chronic leg pain. Nevertheless, these and other invasive methods are being used to an increasing extent. Spontaneous healing and the possibilities of the patient to become pain-relieving for themselves are neglected and increased risks are accepted.Therapeutic approaches fostering self-efficacy by reconditioning physical and mental capability and improving positive self-perception ("interdisciplinary multimodal pain therapy") effect superior and sustainable results in subacute and chronic nonspecific back pain. Patients and physicians, however, tend to prefer passive and invasive therapy strategies. The underlying mechanisms should be understood. New thinking is necessary.

Individual differences in attachment anxiety shape the association between adverse childhood experiences and adult somatic symptoms

BACKGROUND

Although prior research has documented the link between adverse childhood experiences (ACEs) and somatic symptoms, it remains unclear why some individuals exposed to ACEs developed somatic symptoms while others did not.

OBJECTIVE

Framed by a biopsychosocial perspective, this study investigated the role of attachment anxiety in the association between ACEs and somatic symptoms in adulthood.

PARTICIPANTS AND SETTING

A total of 662 emerging adults attending college were recruited to respond to an online survey in a computer lab.

METHOD

The computer-based survey included demographic form, the Adverse Childhood Experience Scale, the Experience in Close Relationship Scale-Short Form, and the Somatization Scale of the Symptom Checklist-90-Revised for somatic symptoms. Multivariate regression analyses were used to examine the role of attachment anxiety in the association between ACEs and somatic symptoms.

RESULTS

The results indicated that ACEs positively correlated with attachment anxiety and somatic symptoms; and attachment anxiety and somatic symptoms were positively correlated. Moreover, the results indicated a significant effect of interaction between ACEs and attachment anxiety on somatic symptoms, suggesting a moderating role of attachment anxiety. Subsequent simple slope test revealed that attachment anxiety intensified the strength of relation between ACEs and somatic symptoms; but when the level of attachment anxiety was low, ACEs and somatic symptoms were not related.

CONCLUSION

Individual differences in attachment anxiety shape the association of adverse childhood experiences with somatic symptoms. Targeting and reformulating anxious working models of attachment may help ameliorate vulnerability to somatic symptoms in individuals exposed to ACEs.

The relationship between attachment and somatoform symptoms in children and adolescents: A systematic review and meta-analysis

OBJECTIVE

Problems in childhood and adolescence are often present with recurring physical signs of illness, called somatoform symptoms. These symptoms are a common reason for consultation at both paediatric care and psychotherapeutic/psychiatric praxis. We propose that attachment is a possible predictive factor. This article provides a systematic overview of the existing research literature concerning the relationship between attachment and somatoform symptoms in children and adolescents.

METHODS

A systematic search for empirical articles from 1990 up to August 2018 focusing on this association was conducted. Out of six databases, 4994 studies were detected by using defined keywords. One study was added identified by checking reference lists. Finally, 15 studies were selected, which were the bases for the narrative review. Ten studies were included in meta-analysis.

RESULTS

Combining study results, we found that attachment cannot solely predict somatoform symptoms. Mixed results are shown. The quantitative analysis substantiated these narrative results, revealing a small but significant combined effect size of Δ ≈ .12 (95% CI .04 - .19).

CONCLUSIONS

The findings suggest that a relationship exists, but further investigations need to demonstrate that these are not only superficial. There are many developmental factors that affect the relationship between attachment and somatoform symptoms in children and adolescents. Further research should explore this interplay in order to gain a holistic and comprehensive understanding of the underlying mechanisms that lead to these correlations and to discover possible predicting factors.

Associations between attachment and pain: From infant to adolescent

Pain experience is a negative complex phenomenon influenced by several mechanisms. Attachment processes may affect the way in which individuals experience and signal pain. Hence, in the last two decades, the role of attachment quality has drawn attention in pain research and practice. However, previous reviews on this topic focused on adulthood and/or specific types or pain. We conducted a narrative review examining the association between attachment and different pain conditions from infancy to adolescence. Two independent researchers searched scientific databases for relevant papers. A total of 17 articles were included. Results highlight the following: (a) children and adolescents with chronic idiopathic pain showed low rates of attachment security compared to control groups; (b) pain conditions are consistently associated with elevated rates of at-risk pattern of attachment and information processing; and (c) the presence of unresolved trauma or loss is higher in children and adolescent who experienced pain compared to healthy controls. Despite the significance of these empirical evidences, the impact of caregiving environment and interpersonal context on pain experience in infancy and preschool age is poorly investigated compared to adulthood. Research on pain and attachment needs to be extended since the majority of the studies are limited to specific pain conditions. Future research should investigate the role of anxious attachment on procedural pain and transition from acute to chronic pain, testing new conceptual models. These findings shed light on the importance of relational factors and psychosocial vulnerabilities in pain clinical practice. An attachment-informed approach to pain will help health professionals to offer adequate support during procedures and to increase effectiveness of interventions. A developmental perspective is needed to integrate familial and relational contribution into a multimodal assessment and treatment of pain. Longitudinal studies are recommended.

The mediating role of difficulties in emotion regulation on attachment styles of adolescents with conduct disorders

Adolescence is a period of achieving emotion regulation skills. One of the main responsibilities of adolescents is to learn adaptive emotion regulation and personal autonomy. The purpose of this study was to investigate the mediating role of difficulties in emotion regulation in the attachment styles of adolescents with conduct disorders. This was a cross-sectional and correlational study. The study consisted of 105 adolescent residing in detention centers in the southeast of Iran using multi-stage random sampling. Data were collected using various questionnaires such as the Inventory of Parents and Peer Attachment-Revised (IPPA-R), the Difficulties of Emotion Regulation Scale (DERS), and the Strength and Difficulties Questionnaire (SDQ). Information was analyzed using path analysis. The results show parental attachment and difficulties in emotion regulation significantly contribute to the prediction of conduct problems. A sense of alienation causes conduct disorders through disturbance in emotional regulation, but trust and communication with parents are only indirectly related to conduct disorders by disturbances in emotional regulation. As attachment is closely correlated with emotional regulation and difficulties in emotion regulation also lead to the conduct disorders, it is suggested to train emotion regulation in adolescents and their families with the aim of shaping relationships that will lead to the formation of a secure attachment style in the child.

Measurement of heart rate variability and cognitive abilities based on attachment styles in children with chronic medical conditions

Recognizing the biopsychosocial dimensions of chronic medical conditions in children and preparing them to adapt to medical processes is one of the most significant issues in the field of health psychology. The aim of this study was to measure heart rate variability and cognitive abilities based on attachment style in children with chronic medical conditions. To this end, 45 children aged 12-15 years who had received a diagnosis of a chronic medical disease and were matched with the inclusion/exclusion criteria, were entered the study using available sampling method. These children were assigned to three groups of secure, avoidance and anxiety attachment style based on the Collins and Reid Attachment Scale. These groups had been demographically homogeneous. Then heart rate variability and cognitive abilities were measured. One-way ANOVA results showed a significant difference between the three groups in the heart rate variability and cognitive abilities. Post hoc test showed that children with secure attachment style had higher efficiency in heart rate variability and cognitive abilities. These results indicate that attachment style is one of the factors influencing the health status of children with chronic medical illness. These findings highlight the importance of paying attention to psychological factors, especially attachment and its role in the health status of children with chronic medical conditions.

Effectiveness of an Attachment-Informed Working Alliance in Interdisciplinary Pain Therapy

Attachment theory provides a useful framework for understanding individual differences in pain patients, especially with insecure attachment shown to be more prevalent in chronic pain patients compared to the general population. Nevertheless, there is little evidence of attachment-informed treatment approaches for this population. The present study compares outcomes from two different attachment-informed treatment modalities for clinicians, with outcomes from treatment as usual (TAU). In both intervention groups (IG1 and IG2), clinicians received bi-monthly training sessions on attachment. Additionally, clinicians in IG1 had access to the attachment diagnostics of their patients. All treatments lasted for four weeks and included a 6-month follow up. A total of 374 chronic pain patients were recruited to participate in this study (TAU = 159/IG1 = 163/IG2 = 52). Analyses were carried out using multilevel modeling with pain intensity as the outcome variable. Additionally, working alliance was tested as a mediator of treatment efficacy. The study was registered under the trial number DRKS00008715 on the German Clinical Trials Register (DRKS). Findings show that while IG2 was efficient in enhancing treatment outcomes, IG1 did not outperform TAU. In IG2, working alliance was a mediator of outcome. Results of the present study indicate that attachment-informed treatment of chronic pain can enhance existing interdisciplinary pain therapies; however, caveats are discussed.

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.