Assessing patterns of adult attachment in medical patients

Anxious Attachment Style Predicts Dietary Adherence 1-Year Post-bariatric Surgery

PURPOSE

Adherence to dietary guidelines is critical for optimizing health and weight outcomes after metabolic and bariatric surgery, yet many patients have difficulty. The purpose of this study was to identify the types and frequency of post-surgery non-adherent dietary behaviors and to determine pre-surgery predictors of adherence at 1-year post-surgery.

MATERIALS AND METHODS

We completed a prospective cohort study of 348 adults who underwent sleeve gastrectomy (n = 25) or Roux-en-Y gastric bypass (n = 323) at an academic medical center between 2013 and 2017. Pre- and post-surgery parameters were demographics, adherence to dietary recommendations and mental health symptoms. Descriptive statistics and regression analyses were used.

RESULTS

Pre-surgery, 264 (75.9%) participants were classified as adherent to nutrition recommendations by a Registered Dietitian (RD). At 1-year post-surgery, 203 (58.3%) were adherent, a statistically significant decrease (p < 0.05). The three most frequent non-adherent eating behaviors were insufficient protein intake (32.4%), inadequate vitamin intake (26.1%), and grazing (21.1%). Pre-surgery predictors in the bivariate regression analysis were anxious attachment (p = 0.01), poorer emotion regulation (p = 0.01), poorer perceived social support (p = 0.01), and RD disposition of dietary adherence (p = 0.02). In the best subset multivariate regression analysis, anxious attachment emerged as the significant predictor.

CONCLUSION

Several types of non-adherent eating behaviors were identified. Pre-surgery, anxious attachment style, dietary adherence, emotion regulation, and perceived social support were predictors of adherence to dietary guidelines 1-year post-surgery. These factors should be assessed and patients provided with relevant support and education.

Gestational diabetes perception profiles based on attachment style: a cross-sectional study

AIMS

Gestational diabetes (GDM) is a prevalent complication in pregnancy that requires effective self-management, which can be influenced by illness perceptions. Moreover, behavioral regulation can be affected by attachment styles. Thus, our study aimed to identify common GDM perception profiles and test their association with attachment styles.

METHODS

In this cross-sectional study, 446 women completed the Relationship Questionnaire (RQ), the Brief Illness Perception Questionnaire (BIPQ), and additional items about GDM diagnosis, information, competence, adherence, behavioral change. Latent profile analysis (LPA) was conducted to determine GDM perception profiles. Multinomial logistic regression followed to calculate the association between GDM perception profiles and attachment styles.

RESULTS

Three distinct profiles emerged: coping (n = 172, 38.6%)-characterized by the most positive GDM perception, burdened (n = 222, 49.8%)-indicating the emotional burden of the disease, and resourceless (n = 52, 11.7%)-reporting lack of resources (i.e. information, competence). Women with insecure attachment styles were more likely to develop a burdened GDM perception profile. Specifically, the expression of a fearful (OR = 1.184 [95%CI: 1.03; 1.36], p = 0.016) and a preoccupied (OR = 1.154 [95%CI: 1.01; 1.32], p = 0.037) attachment style increased the likelihood for a burdened perception profile, while a secure attachment style (OR = 10.791 [95%CI: 0.65; 0.96], p = 0.017) decreased likelihood for developing resourceless GDM perception profile.

CONCLUSIONS

Three GDM perception profiles were identified and the role of attachment styles in shaping these perceptions was confirmed. Further studies are needed to investigate whether a tailored treatment approach based on the predominant attachment style could lead to more positive GDM perceptions, improved glycemic control, and better perinatal outcomes.

Changes in attachment dimensions during the treatment of acute post-traumatic stress disorder in sexually assaulted Brazilian women

Introduction

Attachment patterns are established during early childhood; however, extreme experiences throughout life may change this structure, either toward attachment security or insecurity. We analyzed changes in attachment dimensions in women with acute post-traumatic stress disorder (PTSD) following sexual assault, that were randomized to a 14-week treatment with either the medication sertraline or Interpersonal Psychotherapy.

Methods

Seventy-four adult women who presented significant reduction in PTSD symptoms across the trial responded to the Revised Adult Attachment Scale at baseline, on week 8 of treatment, and at the end of the trial, on week 14. We fitted a generalized linear model to explain the attachment anxiety and avoidance scores at baseline. A generalized linear mixed model investigated how attachment dimensions changed over time. Socioeconomic data, treatment type, history of childhood trauma, and PTSD severity over the 14-week period were the considered covariates.

Results

At baseline, attachment anxiety was associated with a history of early trauma. Attachment anxiety remained stable during the follow-up. Attachment avoidance, on the other hand, significantly increased from baseline to week 14. Higher avoidance was observed in patients with higher total PTSD scores and on the cluster of hyperarousal symptoms. Races other than White (black, mixed-race, or Asian) and younger age were associated with higher attachment avoidance.

Discussion

Contrary to our expectations, attachment avoidance increased during follow-up, indicating changes in the interpersonal realm beyond the symptoms of PTSD.

Attachment in close relationships and glycemic outcomes in children with type 1 diabetes

BACKGROUND

Our aim was to determine whether child attachment to parents, parent attachment style, and morning cortisol levels were related to diabetes outcomes measured by average glycated hemoglobin (HbA1c), HbA1c variability over 4 years and time in range (TIR) in children with type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

101 children with T1D and one of their parents were assessed at baseline for child attachment (Child Attachment Interview; CAI) and parent attachment (Relationship Structures Questionnaire; ECR-RS). Serum samples were collected for cortisol measurements before the interviews. HbA1c levels were measured during a 4-year follow-up period at regular 3-monthly visits, and data for TIR were exported from blood glucose measuring devices. Multivariate linear regression models were constructed to identify independent predictors of glycemic outcomes.

RESULTS

More girls than boys exhibited secure attachment to their mothers. The results of the regression models showed that securely attached girls (CAI) had higher average HbA1c than did insecurely attached girls (B = -0.64, p = 0.03). In boys, the more insecure the parent's attachment style, the worse the child's glycemic outcome: the higher the average Hb1Ac (B = 0.51, p = 0.005), the higher the HbA1c variability (B = 0.017, p = 0.011), and the lower the TIR (B = -8.543, p = 0.002).

CONCLUSIONS

Attachment in close relationships is associated with glycemic outcomes in children with T1D, and we observed significant differences between sexes. A sex- and attachment-specific approach is recommended when treating children with less favorable glycemic outcomes. Special attention and tailored support should be offered to securely attached girls in transferring responsibility for diabetes care and at least to male children of insecurely attached parents to prevent suboptimal glycemic control. Further studies in larger samples and more daily cortisol measurements may help us better understand the links between stress response, attachment and T1D.

Attachment style and post-bariatric surgery health behaviours: the mediating role of self-esteem and health self-efficacy

BACKGROUND

Attachment avoidance and anxiety have been linked to overweight and poor health behaviours, yet the mechanisms that underpin the relationship between attachment and health behaviours are not fully understood. Self-esteem and self-efficacy have been found to differ between attachment styles, rendering these variables potential mediators of the relationship. This longitudinal study investigated the serial mediation between preoperative attachment and 2-year post-operative health behaviours through self-esteem and health self-efficacy.

METHODS

Participants were 263 bariatric surgery patients (75.7% females, aged 47.7 ± 10.4 years, BMI 38.9 ± 3.6 kg/m2) assessed before the operation and again one and two years after the surgery. Patients completed the Experiences for Close Relationships Brief Scale, Rosenberg Self-esteem scale, Weight Efficacy Lifestyle Questionnaire, Bariatric Surgery Self-Management Questionnaire, Exercise Self-Efficacy Scale and the Exercise Behaviour Scale.

RESULTS

Higher preoperative attachment anxiety and avoidance were associated with lower self-esteem one year after bariatric surgery and poorer health self-efficacy two years after the surgery. Self-esteem and health self-efficacy mediated the relationships between preoperative anxious and avoidant attachment and 2- year post-operative diet adherence and physical activity.

CONCLUSIONS

Helping patients to feel more worthy and reinforcing their beliefs about their own competences could lead to higher engagement with healthy lifestyle and adherence to treatment protocols, ultimately helping patients to achieve their goals for bariatric surgery.

CLINICAL TRIAL REGISTRATION

BARIA: Netherlands Trial Register: NL5837 (NTR5992) https://www.trialregister.nl/trial/5837 . Diabaria: ClinicalTrials.gov identifier (NCT number): NCT03330756.

Attachment insecurity predicts outcomes in an ACT-CBT group therapy for adults in a physical rehabilitation centre

Adapting to chronic illness or disability is accompanied by acute and ongoing illness stressors. Psychological factors such as emotional distress and low self-efficacy are common experiences in chronic illness and disability and interfere with adaptation and psychosocial outcomes such as health-related quality of life. Transdiagnostic group psychotherapy may provide a parsimonious approach to psychological treatment in rehabilitation care by targeting shared illness stressors across mixed chronic illnesses and disabilities, and shared processes that maintain psychological symptoms. Attachment theory may explain individual differences in outcomes and help identify individuals at risk of poor health-related quality of life trajectories. Adults (N=109) participated in an 8-week process-based ACT-CBT psychotherapy group at a tertiary care physical rehabilitation centre between 2016 and 2020. Participants completed measures of emotional distress, self-efficacy, health-related quality of life, and attachment at pre- and post-treatment. Multilevel analyses indicated that patients improved on most outcomes at post-treatment. Attachment anxiety at pre-treatment was associated with more positive outcomes. Reliable change indices suggest clinically meaningful change for the majority of participants, but most were not recovered. Results provide proof-of-concept for the transdiagnostic group intervention and suggest that a longer course of treatment may be clinically indicated. Results warrant replication with larger and more diverse samples, and more robust designs.

Childhood adversity and attachment anxiety predict adult symptom severity and health anxiety

BACKGROUND

Childhood adversity is associated with somatization, including physical symptom burden and health anxiety. Attachment theory offers a developmental framework to understand adult somatization, as attachment phenomena are theoretically and empirically related to physiological regulation, affect regulation, and childhood adversity, all of which are relevant to somatization.

OBJECTIVE

The purpose of this study was to identify the pathways by which childhood adversity and attachment insecurity influence physical symptom burden and health anxiety in adults.

PARTICIPANTS AND SETTING

Three hundred and fifty-one family medicine patients from a teaching hospital in Toronto, Canada.

METHODS

A cross-sectional survey study was conducted to assess adverse childhood experiences, attachment insecurity, health anxiety and physical symptom severity in primary care patients. Path Analysis using structural equation modeling (AMOS V.26, IBM, 2019) was used to test the model in which childhood adversity, attachment anxiety, attachment avoidance, symptom severity interact to influence health anxiety.

RESULTS

The majority of the participants were white (66%), had completed post-secondary education (68%), and reported themselves to be in very good to excellent health (62%). Childhood adversity, attachment anxiety, attachment avoidance, health anxiety and symptom severity are all significantly correlated (ranges of r_s = 0.29 to 0.63). Childhood adversity has a significant indirect effect on health anxiety with attachment anxiety and symptom severity as serial mediators (β_indirect = 0.237, p = .001 and β_direct = 0.065, p = .244).

CONCLUSIONS

Overall, this model extends our understanding of the processes underlying adult somatization. Findings support that childhood adversity and attachment anxiety are predictors of symptom severity and health anxiety.

Working alliance and attachment orientations in the patient-oncologist relationship

OBJECTIVE

Accumulating research suggests that the working alliance (WA) is a key component in the patient-oncologist relationship. Attachment theory provides a useful framework for understanding this alliance within the oncological setting, where patients' attachment systems are often activated. This study examined the association between attachment orientations of both dyad members (i.e., patient and oncologist) and patients' WA experience. It also probed whether this link was mediated by patients' attachment-related attitudes towards the oncologist, using a recently developed measure.

METHOD

Oncologists and their respective patients (N = 113: 103 patients, 10 oncologists) were sampled at oncological clinics. Eligible patients filled out online measures of the WA, attachment-related attitudes, and attachment orientations. The later was also completed by oncologists.

RESULTS

Structural equation modeling demonstrated that both patients' and oncologists' avoidant attachment orientation inversely predicted patients' WA experience, via patients' experience of feeling unsupported by their oncologists.

CONCLUSIONS

Findings suggest that attributes of both members of the patient-oncologist dyad are related to patients' WA experience, and that attachment-related attitudes towards oncologists occur within this relationship. Oncologists' understanding of patients' unique attachment behaviors, as well as their own such behaviors, could improve cancer patients' quality of care and illness outcomes. Results represent another step forward in fully exploring whether oncologists can serve as attachment figures for their patients.

Disease course, stress, attachment, and mentalization in patients with inflammatory bowel disease

Inflammatory bowel disease (IBD), including Crohn's disease and ulcerative colitis, are chronic intestinal disorders that requires lifelong treatments. IBD are associated with perceived stress, poor quality of life, and psychopathological disorders. Previous studies have documented that psychological distress and depression are risk factors for IBD. On the other hand, IBD itself might be a source of psychological stress. IBD negatively affect individuals' daily social interactions and close interpersonal relationships. Despite IBD's detrimental effects on quality of life, patients' adherence to medicaments remains low, increasing the risk of relapses and the subsequent worsening of the clinical condition. Drawing on attachment and mentalization theories, we aim to contribute to understanding of the mechanisms involved in the poor quality of social relationships and the tendency for medication non-adherence in patients with IBD. We hypothesize a bidirectional link between IBD and attachment style and related mentalization abilities, where an individual's attachment style refers to a complex and characteristic pattern of relating to self and others and mentalization refers to the process of inferring one's own and others' mental and physical states. This hypothesized link between IBD and insecure attachment style, mediated by reduced mentalizing abilities, may be a risk factor for developing both IBD-related psychological disorders and reduced medication adherence, which could then lead to worsening disease management and prognoses for the disease course. The medication nonadherence is here considered as both an outcome and a risk factor of this vicious circle. We share the view that preventing the worsening of the IBD condition and promoting patients' medication adherence would be possible by considering the circular relationship between IBD, attachment, and mentalization and by promoting reflective functioning in patients with IBD, from the onset of the disease.

Attachment and Mentalizing Abilities in Patients with Inflammatory Bowel Disease

Background

Inflammatory bowel diseases (IBD) are associated with stress, poor quality of life, and attachment insecurity. Mentalization is the human ability to perceive and reason about feelings and psychological dispositions of one's self and others. The chronic disorders are believed to affect patients' mentalizing abilities and to determine a shift towards attachment insecurity in patients affected. In this study, the attachment dimensions and mentalization were assessed in IBD patients and healthy controls. Further knowledge about the interplay among IBD, mentalization, and attachment might shed more light into the psychopathological mechanisms leading to insecurity and vulnerability to stress in IBD.

Methods

A group of 96 IBD patients and 102 healthy controls completed the attachment style questionnaire (ASQ), the reflective functioning questionnaire (RFQ), and the Eyes test, a performance-based measure of mentalization.

Results

Compared to controls, IBD patients have shown more pronounced attachment anxiety and lower scores in the Eyes test. Disease activity was negatively correlated with the Eyes test scores.

Conclusion

These findings have suggested a plausible impact of IBD on mentalization abilities and have provided new insights into the interplay between IBD, deficits in mentalization, and attachment insecurity. IBD patients are highly vulnerable to disease-related stress that may promote impairments in mentalization. Low mentalization might play a central role in the development of attachment insecurity and emotional disturbances in IBD. The present study's results might open new scenarios for psychodynamic approaches to the treatment of the emotional disturbances in IBD based on attachment and mentalization theory.

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.

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.

The experience of medical communication in adults with acute leukemia: Impact of age and attachment security

BACKGROUND

Health care providers' (HCPs) communication with cancer patients provides both information and support. Younger patient age and greater difficulty accepting support (attachment security) have been linked to poorer communication experiences with HCPs. The present secondary data analysis examined the impact of age group and attachment security on perceived communication problems with HCPs in adults with acute leukemia (AL).

METHODS

The sample included 95 younger (age < 40 years) and 225 older (age ≥ 40 years) patients with newly diagnosed or recently relapsed AL. We assessed avoidant and anxious attachment security (reluctance to accept support and fear of its unavailability, respectively) with the modified 16-item Experiences in Close Relationships Scale. The impact of age group and attachment security on perceived communication problems, measured with the Cancer Rehabilitation Evaluation System-Medical Interaction Subscale, was assessed based on the presence and extent of communication problems.

RESULTS

Younger patients (OR = 1.79-1.82, P = .030) and those with greater avoidant (OR = 1.44, P = .001) or anxious attachment (OR = 1.38, P = .009) were more likely to report communication problems. A similar relationship was found between age (β's = -.17-.19, P = .015-.025), avoidant (β = .29, P = .013), or anxious attachment (β = .17, P = .031), and the extent of communication problems. A significant age-group × avoidant-attachment interaction (β = -.31, P = .008) suggested that more avoidant attachment was associated with more perceived communication problems in the younger but not in the older group.

CONCLUSIONS

Younger patients with AL, especially those more reluctant to seek or accept support, perceive more communication problems with their HCPs than older patients. Greater attention by HCPs to their communication with younger patients is needed.

Efficacy of an Attachment-Based Intervention Model on Health Indices in Children with Chronic Disease and Their Mothers

Studies have shown significant relationship between health conditions and attachment. This study aimed to examine an attachment-based intervention model named mother-child-disease triangle (MCDT) on health indices in children with chronic disease and their mothers. This randomized trial study included 22 volunteer children aged 12-18 years undergoing medical treatment for a chronic disease and their mothers. After evaluation by 28-form General Health Questionnaire (GHQ-28), inventory of parent and peer attachment (IPPA), 28-form Child Health Questionnaire (CHQ-28) and Illness Perception Questionnaire (IPQ), the mother-child dyads were paired on the basis of IPPA scores. These pairs were then randomly assigned to an experimental or control group. The experimental group received ten 90-min sessions of MCDT over a 7-week period. Meanwhile, the control group received ten simple conversational sessions as a dummy intervention. In accordance with this study's pre-test/post-test design, both groups were evaluated once again after completing their respective treatment. Multivariate analysis of covariance (MANCOVA) showed members of the experimental group to have significantly stronger attachment and better physiological and psychosocial health than those in the control group. These findings suggest that attachment-based interventions can be used to improve the effectiveness of treatment among children with chronic disease and their mothers.

Relationships Between Adult Attachment Dimensions and Patient-Physician Relationship Quality

Positive associations between attachment insecurity and indicators of poorer patient-physician relationship quality have been found in samples of patients consulting with physicians for a variety of specific medical conditions or needs. The current study was the first to investigate associations between adult attachment characteristics and relationship quality with family physicians. University students (N = 239) completed measures assessing attachment and their relationships with their family physician. Attachment avoidance was associated with poor affective relationship quality and with greater communication difficulties. Attachment anxiety was associated with greater communication difficulties, but was unrelated to affective relationship quality. Those with insecure attachment, particularly those with high levels of avoidance, have poorer relationships with their family physicians than those with more secure attachment.

Attachment styles of People Living with HIV/AIDS

Factors that involve the dynamics in interpersonal relationships and may have consequences in health are still little explored in people living with HIV/AIDS. The aim was to identify the evidences of literature regarding adult attachment style and HIV. It is an Integrative literature review. Seven databases were explored, using the combination of key words and Boolean connectors: "Attachment Style OR Object Attachment AND HIV". A reasonable number of articles addressed attachment among people with HIV as a mediator to post-traumatic stress disorder, depression and stress. The prevalence of insecure attachment in this group was high. Evidence was also found in relation to the attachment as an important factor to adaptation to the diagnosis of HIV, attachment and behavior in interpersonal relationships, and emphasize the possibility of changing the attachment style.

Public Attitudes Toward Guided Internet-Based Therapies: Web-Based Survey Study

BACKGROUND

Internet interventions have been proposed to improve the accessibility and use of evidence-based psychological treatments. However, little is known about attitudes toward such treatments, which can be an important barrier to their use.

OBJECTIVE

This study aimed to (1) determine attitudes toward guided internet interventions, (2) assess its acceptability compared with other internet-based formats, and (3) explore predictors of acceptance.

METHODS

A convenience-sample Web-based survey (N=646) assessed attitudes toward guided internet therapies (ie, perceived usefulness and helpfulness, and advantage relative to face-to-face therapy), preferences for delivery modes (ie, e-preference: guided internet interventions, unguided internet interventions, or videoconferencing psychotherapy), and potential predictors of attitudes and preferences: sociodemographics, help-seeking-related variables, attachment style, and perceived stress.

RESULTS

Although most participants perceived internet interventions as useful or helpful (426/646, 65.9%), a few indicated their advantage relative to face-to-face therapy (56/646, 8.7%). Most participants preferred guided internet interventions (252/646, 39.0%) over videoconferencing psychotherapy (147/646, 22.8%), unguided internet interventions (124/646, 19.2%), and not using internet interventions (121/646, 18.8%; missing data: 1/646, 0.2%). Attachment avoidance and stress were related to e-preference (all P<.05). Moreover, preference for therapist-guided internet interventions was higher for individuals who were aware of internet-based treatment (χ²₆=12.8; P=.046).

CONCLUSIONS

Participants assessed therapist-guided internet interventions as helpful, but not equivalent to face-to-face therapies. The vast majority (523/646, 81.0%) of the participants were potentially willing to use internet-based approaches. In lieu of providing patients with only one specific low-intensity treatment, implementation concepts should offer several options, including guided internet interventions, but not limited to them. Conversely, our results also indicate that efforts should focus on increasing public knowledge about internet interventions, including information about their effectiveness, to promote acceptance and uptake.

The relationship between attachment orientations and the course of depression in coronary artery disease patients: A secondary analysis of the SPIRR-CAD trial

OBJECTIVE

The relationship between attachment orientations and the recovery from depressive symptoms in patients diagnosed with coronary artery disease (CAD) with and without a psychotherapeutic intervention was examined in this study.

METHODS

In a multicenter trial of 570 depressed CAD patients (SPIRR-CAD), assigned to usual care plus either a stepwise psychotherapy intervention or one information session, 522 patients provided attachment data at baseline. Attachment was measured with the Relationship Scales Questionnaire (RSQ), yielding four attachment orientations. The primary outcome was change in Hospital Anxiety and Depression Scale depression (HADS-D) scores from baseline to follow-up at 18 months. Secondary outcomes were HADS-D scores at 1, 6, 12, and 24 months.

RESULTS

Independent of treatment assignment, attachment was related to change in depression at 18 months (p < 0.01) with secure attachment resulting in a significant reduction (-2.72, SE = 0.27) in depression compared to dismissive-avoidant (-1.51, SE = 0.35, p = 0.040) and fearful-avoidant (-0.65, SE = 0.61, p = 0.012) attachment. Patients with anxious-preoccupied attachment showed changes similar to secure attachment (-2.01, SE = 0.47). An explorative subgroup analysis across all assessment time points revealed patients with a dismissive-avoidant attachment benefitted from psychotherapy (average mean difference = 0.93, SE = 0.47, p = 0.048).

CONCLUSION

Attachment played an important role for improvement in depressive symptoms. Only dismissive-avoidant patients seemed to benefit from the intervention. The lack of improvement in fearful-avoidant patients shows a need for specific interventions for this group.

TRIAL REGISTRATION

www.clinicaltrials.govNCT00705965; www.isrctn.com ISRCTN76240576.

Attachment Insecurity in Advanced Cancer Patients: Psychometric Properties of the German Version of the Brief Experiences in Close Relationships Scale (ECR-M16-G)

CONTEXT

Attachment insecurity refers to difficulty in trusting and relying on others in times of need. Its underlying factors attachment anxiety and attachment avoidance have been empirically associated with impaired coping in advanced cancer and, therefore, should be considered in individually tailored medical and psychosocial treatment.

OBJECTIVES

The objective of this study was to evaluate the psychometric properties of the German translation of the Brief Experiences in Close Relationships Scale (ECR-M16-G).

METHODS

We recruited 182 advanced cancer patients from outpatient psycho-oncology clinics of the University Medical Center Hamburg-Eppendorf and the University Medical Center Leipzig, local and external cancer care facilities. We performed confirmatory factor analysis to replicate the higher order factor structure reported in previous research. We conducted item and reliability analysis, also correlation analysis, to examine concurrent validity.

RESULTS

One hundred fifty-eight patients completed the ECR-M16-G (women 61%, mean age 57.9, SD = 11.1). We replicated the factor structure with the subscales Attachment Anxiety and Attachment Avoidance as second-order factors and Worrying about relationships, Frustration about unavailability, Discomfort with close others, and Turning away from others as first-order factors. An adjusted model that interchanged factor loadings of items 4 and 10 showed good fit (Comparative Fit Index = 0.94, Non-Normed Fit Index = 0.93, root mean square error of approximation = 0.05). Subscales showed acceptable to good internal consistency (anxiety α = .81 and avoidance α = .78). Attachment insecurity (mean = 3.1, SD = 1.0) was positively associated with depression, anxiety, demoralization (P < 0.001), and symptom burden (P = 0.02) and negatively associated with spiritual well-being (P < 0.001).

CONCLUSION

The ECR-M16-G is a valid and reliable measure of attachment insecurity in patients with advanced cancer and can be recommended as a tool for clinical care and further research.

Two is a perfect number: Patient–doctor relationship and patient attachment style in palliative care

We tested the association between the palliative patient’s attachment style and the patient–doctor relationship, by means of Revised Adult Attachment Scale and a self-designed, patient–doctor relationship questionnaire. The study included 110 (52 M, 58 F) cancer, hospice patients, aged 36–80 years. We observed 54 percent of secure, 18 percent of dismissive, 9 percent of preoccupied, and 19 percent of fearful styles. Securely attached patients developed significantly ( p < .05) better relationships with doctors than insecure patients. There was no difference in the quality of the patient–doctor relationship among dismissive versus preoccupied versus fearful patients. We argue that attachment theory should be applied in palliative care to improve patients’ quality of life and dying.

Insecure attachment predicts depression and death anxiety in advanced cancer patients

ABSTRACTObjective:The prevalence of depression as well as adjustment and anxiety disorders is high in advanced cancer patients, and research exploring intraindividual factors leading to high psychological distress is underrepresented. Cancer patients' feelings about security and trust in their healthcare providers have a significant influence on how they deal with their disease. The perception of social support is affected by patients' attachment styles and influences their reactions to feelings of dependency and loss of control. We therefore aimed to explore attachment and its association with psychological distress in patients with advanced cancer.

METHOD

We obtained data from the baseline measurements of a randomized controlled trial in advanced cancer patients. Patients were sampled from the university medical centers of Hamburg and Leipzig, Germany. The main outcome measures included the Patient Health Questionnaire, the Death and Dying Distress Scale, the Memorial Symptom Assessment Scale, and the Experience in Close Relationships Scale for assessing attachment insecurity.

RESULTS

A total of 162 patients were included. We found that 64% of patients were insecurely attached (fearful-avoidant 31%, dismissing 17%, and preoccupied 16%). A dismissing attachment style was associated with more physical symptoms but did not predict psychological distress. A fearful-avoidant attachment style significantly predicted higher death anxiety and depression, whereas preoccupied attachment predicted higher death anxiety only. Overall, insecure attachment contributed to the prediction of depression (10%) and death anxiety (14%).

SIGNIFICANCE OF RESULTS

The concept of attachment plays a relevant role in advanced cancer patients' mental health. Healthcare providers can benefit from knowledge of advanced cancer patients' attachment styles and how they relate to specific mental distress. Developing a better understanding of patients' reactions to feelings of dependency and distressing emotions can help us to develop individually tailored advanced cancer care programs and psychotherapeutic interventions.

Psychiatric Aspects of Heart Disease (and Cardiac Aspects of Psychiatric Disease) in Critical Care

Strong emotional reactions are common in patients admitted to cardiac critical care; only some are pathological. Cardiac critical care and associated technologies are associated with predictable psychiatric problems. Many occur as secondary complications of the medical status of the patient, which must be carefully assessed. Depression is common in patients with coronary disease and also for patients with heart failure; treatment is helpful, but persistent depression is associated with elevated morbidity and mortality. Preexisting psychiatric disorders may predispose to heart disease, and they and their treatment may affect critical care management.

Personality Makes a Difference: Attachment Orientation Moderates Theory of Planned Behavior Prediction of Cardiac Medication Adherence

OBJECTIVE

To achieve a comprehensive understanding of patients' adherence to medication following acute coronary syndrome (ACS), we assessed the possible moderating role played by attachment orientation on the effects of attitudes, subjective norms, and perceived behavioral control (PBC), as derived from the Theory of Planned Behavior (TPB; Ajzen, 1991), on intention and reported adherence.

METHOD

A prospective longitudinal design was employed. During hospitalization, ACS male patients (N = 106) completed a set of self-report questionnaires including sociodemographic variables, attachment orientation, and measures of TPB constructs. Six months post-discharge, 90 participants completed a questionnaire measuring adherence to medication.

RESULTS

Attachment orientations moderated some of the predictions of the TPB model. PBC predicted intention and reported adherence, but these associations were found to be significant only among individuals with lower, as opposed to higher, attachment anxiety. The association between attitudes and intention was stronger among individuals with higher, as opposed to lower, attachment anxiety. Only among individuals with higher attachment avoidance, subjective norms were negatively associated with intention to take medication.

CONCLUSIONS

Cognitive variables appear to explain both adherence intention and behavior, but differently, depending on individuals' attachment orientations. Integrating personality and cognitive models may prove effective in understanding patients' health behaviors.

Attachment anxiety predicts depression and anxiety symptoms following coronary artery bypass graft surgery

OBJECTIVE

Depression and anxiety are associated with poor recovery in coronary artery bypass graft (CABG) patients, but little is known about predictors of depression and anxiety symptoms.

DESIGN

We tested the prospective association between attachment orientation, and symptoms of depression and anxiety in CABG patients, 6-8 weeks, and 12 months following surgery.

METHOD

One hundred and fifty-five patients who were undergoing planned CABG surgery were recruited. Patients completed questionnaires measuring attachment, depression, and anxiety prior to surgery, then 6-8 weeks, and 12 months after surgery.

RESULTS

Attachment anxiety predicted symptoms of depression and anxiety at both follow-up time points, whereas attachment avoidance was not associated with depression or anxiety symptoms. The findings remained significant when controlling for baseline mood scores, social support, demographic, and clinical risk factors.

CONCLUSION

These results suggest that attachment anxiety is associated with short-term and long-term depression and anxiety symptoms following CABG surgery. These results may offer important insight into understanding the recovery process in CABG surgery. Statement of contribution What is already known on this subject? Depression and anxiety symptoms are twice more likely to occur in coronary artery bypass graft (CABG) populations than in any other medical group. Depression and anxiety are associated with poor recovery following cardiac surgery. Predictors of depression and anxiety in CABG patients have been underexplored. What does this study add? This study highlights the importance of close interpersonal relationships on health. Attachment anxiety was prospectively associated with higher levels of depression and anxiety. These results add to understanding mechanisms linked to recovery following CABG.

Attachment and perceived stress in patients with ulcerative colitis, a case-control study

WHAT IS KNOWN ON THE SUBJECT?: Ulcerative colitis (UC) is a chronic inflammatory disorder associated with high perceived psychological stress. The attachment theory provides a psychodynamic perspective to investigate the relationship between close interpersonal relationships and stress in UC. Researchers have hypothesized that the chronic illness might affect personality trait as the attachment style of patients. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: UC patients exhibit a more pronounced attachment insecurity that, in turn, resulted as a determinant of psychological stress. This study suggests that UC could determine a shift towards insecurity in the attachment style that, in turn, promotes psychological stress and increases the risk of psychopathologies. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The more accurate knowledge of attachment insecurity in patients with chronic disorders such as UC may help the nurses to face with often dysfunctional patients' styles of manifesting distress, patterns of help seeking and expectations of health professionals. The knowledge of psychopathological mechanisms in patients with UC could improve the prevention and treatment of psychological disorders in affected patients.

ABSTRACT

Introduction Ulcerative colitis (UC) is a chronic disorder characterized by recurrent intestinal symptoms. The attachment theory provides a psychodynamic perspective to investigate the relationship between interpersonal relationships and stress in UC. Aim The aim of this study was to compare the attachment dimensions between UC patients and controls and to evaluate the impact of these dimensions on perceived stress in patients. Method In all, 101 patients with UC completed the attachment style questionnaire and the perceived stress questionnaire (PSQ). Clinical and psychometric parameters were added as predictor variables in a regression with the PSQ score as dependent variable. One hundred and five healthy subjects took part in the study as controls. Results Compared to controls, UC patients exhibited greater scores in relationships as secondary, need for approval and preoccupation with relationships. In UC, disease activity, confidence and preoccupation with relationships resulted predictors of perceived stress. Discussion Compared to healthy controls, UC patients exhibited more pronounced attachment insecurity that, in turn, was a significant predictor of the perceived stress. Implications for practice The knowledge of attachment insecurity may help the nurses and all health care providers to face with dysfunctional patients' styles of manifesting distress, help seeking and expectations of health professionals.

High Prevalence of Insecure Attachment in Patients with Primary Hypertension

Hypertension is a major cardiovascular (CV) risk factor and is predicted by heightened CV reactivity to stress in healthy individuals. Patients with hypertension also show an altered stress response, while insecure attachment is linked to a heightened stress reactivity as well. This is the first study aiming to assess attachment representations in patients with primary hypertension and to investigate their CV responses when their attachment system is activated. We studied 50 patients (38 men, 12 women) with primary hypertension. The Adult Attachment Projective Picture System (AAP), a widely used and validated interview, was performed to measure the patients' attachment representations, and to activate their attachment system. Blood pressure and heart rate were measured after 10 min at rest prior to and directly after the AAP interview. Mood and state anxiety were assessed using the Multidimensional Mood State Questionnaire (MDBF) and the State Trait Anxiety Inventory-State (STAI-S) before and after the experiment. The prevalence of insecure attachment (dismissing, preoccupied, unresolved) in hypertensive patients was predominant (88%), while in non-clinical populations, only about 50% of individuals had insecure attachment patterns. Blood pressure (p < 0.001), heart rate (p = 0.016), and rate pressure product (p < 0.001) significantly increased in response to the attachment interview. Secure attached patients showed the highest rise in systolic blood pressure (p = 0.020) and the lowest heart rate compared to the other attachment groups (p = 0.043). However, attachment representation showed no significant group or interaction effects on diastolic blood pressure (DBP) and rate pressure product. Insecure attachment was highly over-represented in our sample of patients with primary hypertension. Additionally, a robust CV response to the attachment-activating stimulus was observed. Our data suggest that insecure attachment is significantly linked to primary hypertension, which implies the need for further investigations to evaluate attachment insecurity as a possible risk factor for hypertension.

Can patients be 'attached' to healthcare providers? An observational study to measure attachment phenomena in patient-provider relationships

OBJECTIVES

To develop and assess the validity of measures of patients' attachment-related perceptions of experiences with healthcare providers (HCPs).

SETTING

Online survey.

PARTICIPANTS

181 people provided consent and 119 completed the survey (66%). Most participants were women (80%).

PRIMARY AND SECONDARY OUTCOME MEASURES

Questions were developed to assess possible attachment functions served by an HCP and patients' attachment-related attitudes towards an HCP. Scales were constructed based on exploratory factor analysis. Measures of adult attachment, therapeutic alliance, perceived HCP characteristics and health utilisation were used to validate scales.

RESULTS

Possible safe haven and secure base functions served by HCPs were strongly endorsed. A model with good fit (root mean square error of approximation=0.056) yielded 3 factors: 'HCP experienced as supportive and safe' (SUPPORT, α=0.94), 'HCP experienced as aversive' (AVERSE, α=0.86) and 'more and closer contact wanted with HCP' (WANT, α=0.85). SUPPORT was correlated with positive HCP characteristics and not with attachment insecurity. AVERSE was inversely correlated with positive HCP attributes and correlated with attachment insecurity. WANT was unrelated to positive HCP attributes, but correlated with attachment insecurity. Frequency of HCP contact was related to WANT (Kruskal-Wallis=21.9, p<0.001) and SUPPORT (Kruskal-Wallis=13.2, p=0.02), but not to AVERSE (Kruskal-Wallis=1.7, p=0.89).

CONCLUSIONS

Patients attribute attachment functions of secure base and safe haven to HCPs. SUPPORT is related to positive appraisal of HCP characteristics; AVERSE is associated with discomfort in the HCP relationship that is related with perceived HCP characteristics and patients' insecure attachment; WANT is associated with unmet needs for connection with an HCP related to insecure attachment, but not to perceived HCP characteristics. These scales may be useful in studying the application of attachment theory to the HCP-patient relationship.

Attachment anxiety predicts poor adherence to dietary recommendations: an indirect effect on weight change 1 year after gastric bypass surgery

BACKGROUND

Weight loss after gastric bypass surgery depends on the adoption of healthy dietary recommendations, which may be influenced by psychological issues and patients' attachment representations (habitual states of mind with respect to interpersonal relations). The present study tests (1) whether attachment representations are associated with dietary adherence, (2) whether dietary adherence and weight loss are correlated and (3) whether dietary adherence mediates the relation of attachment representations with weight reduction after gastric bypass surgery. Besides attachment representations, psychological problems are examined.

METHODS

This longitudinal study included 105 patients who had a laparoscopic Roux-en-Y gastric bypass operation. Current and past psychological problems and attachment representations were assessed before surgery. Dietary adherence was assessed 6 and 12 months postsurgery. Patients' weight and height were collected from medical records. Multiple linear and logistic regression analyses and mediation analyses using bootstrapping resampling procedures were conducted.

RESULTS

Of all examined predictor variables, attachment anxiety, i.e., fear of social rejection and abandonment, was most strongly associated with low dietary adherence at both 6 months (p = 0.009) and 12 months (p = 0.006) postsurgery. Dietary adherence 6 months postsurgery was associated with weight loss 1 year after the operation (p = 0.003). Dietary adherence at 6 months (β = 0.51; 95% confidence interval (CI) = 0.19-1.04) mediated the association between preoperative attachment anxiety and postoperative weight loss.

CONCLUSIONS

The results suggest that more anxiously attached patients are less adherent to dietary recommendations 6 months after gastric bypass surgery, influencing weight loss in a negative way during the first year after surgery.

Individual risk factors for physician boundary violations: the role of attachment style, childhood trauma and maladaptive beliefs

OBJECTIVE

The assessment and remediation of boundary-challenged healthcare professionals is enhanced through examination of individual risk factors. We assessed three such factors--attachment style, childhood trauma and maladaptive beliefs--in 100 attendees (mostly physicians) of a CME professional boundaries course. We propose a theoretical model which draws a causal arc from childhood maltreatment through insecure attachment and maladaptive beliefs to elevated risk for boundary violations.

METHODS

We administered the Experiences in Close Relationship Questionnaire (ECR-R), Childhood Trauma Questionnaire (CTQ), and Young Schema Questionnaire (YSQ) to 100 healthcare professionals (mostly physicians) attending a CME course on professional boundaries. Experts rated participant autobiographies to determine attachment style and early adversities. Correlations and relationships among self- and expert ratings and between different risk factors were examined.

RESULTS

Five percent of participants reported CTQ total scores in the moderate to severe range; eleven percent reported moderate to severe emotional neglect or emotional abuse. Average attachment anxiety and attachment avoidance were low, and more than half of participants were rated “secure” by experts. Childhood maltreatment was correlated with attachment anxiety and avoidance and predicted expert-rated insecure attachment and maladaptive beliefs.

CONCLUSION

Our findings support a potential link between childhood adversity and boundary difficulties, partly mediated by insecure attachment and early maladaptive beliefs. Furthermore, these results suggest that boundary education programs and professional wellness programs may be enhanced with a focus on sequelae of childhood maltreatment, attachment and common maladaptive thinking patterns.

Associations between adult attachment and: oral health-related quality of life, oral health behaviour, and self-rated oral health

PURPOSE

Although adult attachment theory has been revealed as a useful theoretical framework for understanding a range of health parameters, the associations between adult attachment patterns and a range of oral health parameters have not yet been examined. The aim of this study was to examine potential associations between attachment insecurity and: (1) oral health-related quality of life (OHRQoL), (2) oral health behaviours, and (3) self-rated oral health. In association with this aim, sample characteristics were compared with normative data.

METHODS

The sample in this cross-sectional study was comprised of 265 healthy adults, recruited via convenience sampling. Data were collected on attachment patterns (Experiences in Close Relationships Scale-Short Form, ECR-S), OHRQoL (Oral Health Impact Profile-14, OHIP-14), oral health behaviours (modified Dental Neglect Scale, m-DNS), and self-rated oral health (one-item global rating of oral health). Multivariate regression models were performed.

RESULTS

Both dimensions of attachment insecurity were associated with lowered use of favourable dental visiting behaviours, as well as decreased OHRQoL for both overall well-being and specific aspects of OHRQoL. Attachment avoidance was linked with diminished self-rated oral health.

CONCLUSIONS

This study supports the potential value of an adult attachment framework for understanding a range of oral health parameters. The assessment of a client's attachment pattern may assist in the identification of people who are at risk of diminished OHRQoL, less adaptive dental visiting behaviours, or poorer oral health. Further research in this field may inform ways in which attachment approaches can enhance oral health-related interventions.

Depression, patient characteristics, and attachment style: correlates and mediators of medication treatment adherence in a racially diverse primary care sample

Background

The depth and breadth of problems related to depressive symptomatology and optimal treatment outcomes, including medication treatment adherence, have long been documented in the literature. Missing are clear explanations as to what factors and patient characteristics may account for lack of medication treatment adherence.

Objectives

The two objectives of the current study were to examine the predictive strength of depression, patient characteristics, and patient attachment style regarding medication treatment adherence and to consider the extent to which attachment styles mediate the relation between depression and medication treatment adherence.

Method

Participants in the present study were 237 racially diverse American primary care patients with a diagnosis of hypertension who were participants in a clinical trial. Depression, patient characteristics, attachment style, and medication treatment adherence were assessed.

Results

Partly consistent with our four hypotheses, the following results were found: (a) Black American, younger, never married, and poorer patients had lower medication treatment adherence (b) depression was significantly associated with lower self-reported medication adherence; (c) insecure–dismissing attachment style was related to lower medication adherence; and (d) insecure–dismissing attachment style mediates the relation between depression and medication treatment adherence by exacerbating the negative association.

Conclusion

Physicians and other primary care providers should consider how depressive symptomatology, patient characteristics, and attachment style may inform the treatment plans they put forward and the extent to which patients may adhere to those treatment plans.

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.

Psychosocial screening and assessment in oncology and palliative care settings

Psychiatric and psychosocial disorders among cancer patients have been reported as a major consequence of the disease and treatment. The problems in applying a pure psychiatric approach have determined the need for structuring more defined methods, including screening for distress and emotional symptoms and a more specific psychosocial assessment, to warrant proper care to cancer patients with psychosocial problems. This review examines some of the most significant issues related to these two steps, screening and assessment of psychosocial morbidity in cancer and palliative care. With regard to this, the many different variables, such as the factors affecting individual vulnerability (e.g., life events, chronic stress and allostatic load, well-being, and health attitudes) and the psychosocial correlates of medical disease (e.g., psychiatric disturbances, psychological symptoms, illness behavior, and quality of life) which are possibly implicated not only in “classical” psychiatric disorders but more broadly in psychosocial suffering. Multidimensional tools [e.g., and specific psychosocially oriented interview (e.g., the Diagnostic Criteria for Psychosomatic Research)] represent a way to screen for and assess emotional distress, anxiety and depression, maladaptive coping, dysfunctional attachment, as well as other significant psychosocial dimensions secondary to cancer, such as demoralization and health anxiety. Cross-cultural issues, such as language, ethnicity, race, and religion, are also discussed as possible factors influencing the patients and families perception of illness, coping mechanisms, psychological response to a cancer diagnosis.

Individual risk factors for physician boundary violations: the role of attachment style, childhood trauma and maladaptive beliefs

OBJECTIVE

The assessment and remediation of boundary-challenged health care professionals is enhanced through examination of individual risk factors. We assessed three such factors - attachment style, childhood trauma and maladaptive beliefs - in 100 attendees (mostly physicians) of a continuing medical education (CME) professional boundaries course. We propose a theoretical model that draws a causal arc from childhood maltreatment through insecure attachment and maladaptive beliefs to elevated risk for boundary violations.

METHODS

We administered the Experiences in Close Relationships Questionnaire Revised (ECR-R), Childhood Trauma Questionnaire (CTQ) and Young Schema Questionnaire (YSQ) to 100 health care professionals attending a CME course on professional boundaries. Experts rated participant autobiographies to determine attachment style and early adversities. Correlations and relationships between self-ratings and expert ratings and among different risk factors were examined.

RESULTS

One fifth of participants reported moderate to severe childhood abuse; sixty percent reported moderate to severe emotional neglect. Despite this, average attachment anxiety and attachment avoidance were low, and more than half of participants were rated "secure" by experts. Childhood maltreatment was correlated with attachment anxiety and avoidance and predicted expert-rated insecure attachment and maladaptive beliefs.

CONCLUSIONS

Our findings support a potential link between childhood adversity and boundary difficulties, partly mediated by insecure attachment and early maladaptive beliefs. Furthermore, these results suggest that boundary education programs and professional wellness programs may be enhanced with a focus on sequelae of childhood maltreatment, attachment and common maladaptive thinking patterns.

Adult attachment and approaches to activity engagement in chronic pain

Individuals with chronic pain exhibit a wide range of coping mechanisms, some of which are maladaptive (eg, activity avoidance or overactivity). The authors of this study aimed to investigate whether individuals may be predisposed to develop a particular maladaptive coping mechanism based on their attachment style (dismissing, preoccupied, fearful or secure), which represents a core feature of their personality.

BACKGROUND:

The way in which individuals with chronic pain habitually approach activity engagement has been shown to impact daily functioning, with both avoidance of one’s daily activities and overactivity (activity engagement that significantly exacerbates pain) associated with more pain, higher levels of physical disability and poorer psychological functioning.

OBJECTIVE:

To provide insight into the development of maladaptive habitual approaches to activity engagement in chronic pain by applying an attachment theory framework.

METHODS:

A sample of 164 adults with chronic pain completed selfreport measures of attachment, approach to activity and pain cognitions. Mediation analyses were undertaken to examine the direct association between attachment variables and maladaptive approaches to activity, and to test for the mediating role of pain cognitions (catastrophizing and thought suppression).

RESULTS:

Results demonstrated that higher levels of secure attachment were associated with lower levels of activity avoidance, which was fully mediated by lower levels of pain catastrophizing; higher levels of preoccupied or fearful attachment were directly associated with higher levels overactivity; higher levels of preoccupied attachment were associated with higher levels of activity avoidance, which was partially mediated by higher levels of pain catastrophizing; and higher levels of fearful attachment were indirectly associated with higher levels of activity avoidance through higher levels of catastrophizing.

CONCLUSIONS:

These results provide preliminary support for the suggestion that insecure attachment may be a source of vulnerability to the development of disabling activity patterns in chronic pain.

Attachment and the metabolic syndrome in midlife: the role of interview-based discourse patterns

OBJECTIVE

Adult attachment discourse patterns and current family relationship quality were examined as correlates of health behaviors and number of metabolic syndrome (MetS) criteria met, and as mediators of the link between childhood adversity and these health outcomes.

METHODS

A sample of 215 white/European American and black/African American adults aged 35 to 55 years were examined using a cross-sectional study design. Discourse was assessed with the Adult Attachment Interview, using coherence (a marker of attachment security), unresolved trauma/loss (a marker of disorganized cognitions related to trauma or loss), and idealization (minimizing stressful experiences and their impact) scores. Relationship quality, adverse childhood experiences, and current depressive symptoms were assessed, as were health behaviors of diet, exercise, and smoking. MetS includes obesity, elevated blood pressure, elevated fasting glucose, high triglycerides, and low high-density lipoprotein cholesterol.

RESULTS

Using path analysis and including childhood adversity severity and depressive symptoms in the model, both Adult Attachment Interview coherence and unresolved trauma/loss were directly linked to the number of MetS criteria (r = 0.186 and r = 0.170, respectively). Idealization was indirectly linked to MetS through poor diet (r = 0.183). The final model explained 21% of the variance in scores for the number of MetS criteria met.

CONCLUSIONS

Insecure adult attachment is associated with increased risk of MetS.

Validating relationships among attachment, emotional intelligence and clinical communication

CONTEXT

In a previous study, we found that emotional intelligence (EI) mediates the negative influences of Year 1 medical students' attachment styles on their provider-patient communication (PPC). However, in that study, students were examined on a relatively straightforward PPC skill set and were not assessed on their abilities to elicit relevant clinical information from standardised patients. The influence of these psychological variables in more demanding and realistic clinical scenarios warrants investigation.

OBJECTIVES

This study aimed to validate previous research findings by exploring the mediating effect of EI on the relationship between medical students' attachment styles and their PPC across an ecologically valid PPC objective structured clinical examination (OSCE).

METHODS

Year 2 medical students completed measures of attachment (the Experiences in Close Relationships-Short Form [ECR-SF], a 12-item measure which provides attachment avoidance and attachment anxiety dimensional scores) and EI (the Mayer-Salovey-Caruso Emotional Intelligence Test [MSCEIT], a 141-item measure on the perception, use, understanding and management of emotions), prior to their summative PPC OSCE. Provider-patient communication was assessed using OSCE scores. Structural equation modelling (SEM) was used to validate our earlier model of the relationships between attachment style, EI and PPC.

RESULTS

A total of 296 of 382 (77.5%) students participated. Attachment avoidance was significantly negatively correlated with total EI scores (r = -0.23, p < 0.01); total EI was significantly positively correlated with OSCE scores (r = 0.32, p < 0.01). Parsimonious SEM confirmed that EI mediated the negative influence of attachment avoidance on OSCE scores. It significantly predicted 14% of the variance in OSCE scores, twice as much as the 7% observed in the previous study.

CONCLUSIONS

In more demanding and realistic clinical scenarios, EI makes a greater contribution towards effective PPC. Attachment is perceived to be stable from early adulthood, whereas EI can be developed using targeted educational interventions. The validation of this theoretical model of PPC in Year 2 medical students strengthens the potential educational implications of EI.

Attachment and quality of life in patients with inflammatory bowel disease

PURPOSE

Inflammatory bowel diseases (IBD) are chronic disorders affecting psychological well-being, quality of life (QOL), social interactions, and close interpersonal relationships of patients affected. The attachment theory provides a theoretical framework to evaluate the quality of close interpersonal relationships in the context of chronic disorders. The aims of this study were to compare the attachment dimensions between IBD patients and healthy controls and to evaluate the impact of these dimensions on QOL in IBD patients.

METHODS

One hundred three consecutive IBD outpatients (70 with Crohn's disease and 33 with ulcerative colitis) were recruited in the IBD Unit of the University of Bologna. They were clinically evaluated and filled out the questionnaire Short Form health survey-36 (SF-36), assessing QOL, and the attachment style questionnaire (ASQ), assessing attachment dimensions. One hundred three matched healthy subjects filled out the same questionnaires and represented the control group.

RESULTS

IBD patients exhibited worst scores in the QOL measures (both physical and mental health) and in the attachment dimensions Relationships as secondary and Preoccupation with relationships. In IBD, the significant predictors of physical health were disease activity and disease type, while the significant predictors of mental health were disease activity and type, surgery, and the attachment dimensions Confidence and Preoccupation with relationships.

CONCLUSIONS

Compared to controls, in IBD patients, the close interpersonal relationships are characterized by attachment insecurity that, in turn, is a significant predictor of QOL. These findings suggest plausible insights for psychological interventions in IBD patients with deterioration in QOL.

Breast cancer screening: the role of attachment

Attachment style is the dispositional way in which a person relates to others, and differences in attachment characteristics may offer insight into why many women do not adhere to breast screening guidelines. While mammograms involve contact with medical professionals, breast self-examination (BSE) does not, and may be preferable for women who dislike interpersonal vulnerability. As such, differences in the attachment characteristics that predict mammography versus BSE utilisation may indicate whether attachment related motivations are relevant to both interpersonal examinations and independent self-care behaviours. The current report examined how attachment dimensions predicted the frequency of mammography and BSE in a sample of 1204 ethnically diverse women from Brooklyn, New York. Participants completed measures of mammography and BSE frequency, and attachment, together with demographic, health care context and emotional predictors of screening. Multiple regressions showed that attachment dimensions predicted both mammography and BSE screening even when controlling for established predictors and emotion relevant variables. As hypothesised, fearful avoidance predicted fewer mammograms and BSEs, while preoccupation predicted more frequent BSEs. Consistent with some prior work in male cancer screening, greater attachment security also predicted fewer mammograms while degree of dismissiveness was not associated with screening frequencies. Understanding the psychosocial predictors of screening may help identify low screeners, and guide the development of targeted interventions that are better suited to the interpersonal preferences of older women.

Coping style as a mediator between attachment and mental and physical health in patients suffering from morbid obesity

OBJECTIVE

The presence of mental health problems and limitations in physical functioning is high in patients suffering from morbid obesity. The purpose of the current study was to examine the mediating role of coping style in the relationship between attachment representations and mental health and physical functioning in a morbidly obese population.

METHOD

A total of 299 morbidly obese patients who were referred to the Slotervaart bariatric surgery unit in Amsterdam, the Netherlands, completed self-report questionnaires assessing adult attachment style (Experiences in Close Relationship-Revised Questionnaire), coping style (Utrecht Coping List), and patients physical functioning and mental health (Short Form-36).

RESULTS

Attachment anxiety (beta = -.490, p < .001) and attachment avoidance (3 = -.387, p < .001) were both found to be related to mental health. In addition, attachment anxiety was also found to be related to physical functioning (beta = - .188,p < .001). Coping style partly mediated these associations.

CONCLUSIONS

Findings suggest that coping mediates the association between attachment anxiety and attachment avoidance on the one hand and mental health and physical functioning in patients with morbid obesity on the other hand.

Lower levels of trust in one's physician is associated with more distress over time in more anxiously attached individuals with cancer

OBJECTIVE

In the present study, we investigated individual differences in the outcome of patient-physician trust when confronted with cancer from an attachment theoretical perspective. We expected that lower levels of trust are associated with more emotional distress and more physical limitations within the first 15 months after diagnosis, especially in those who score relatively high on attachment anxiety. No such association was expected for more avoidantly attached individuals.

METHOD

A group of 119 patients with different types of cancer (breast, cervical, intestinal and prostate) completed questionnaires concerning trust (short version of the Wake Forest Physician Trust Scale) and attachment (Experiences in Close Relationship scale Revised) at 3 months after diagnosis. Emotional distress (Hospital Anxiety and Depression Scale) and physical limitations (physical functioning subscales of the European Organization for Research and Treatment of Cancer, Quality of Life Questionnaire-C30) were assessed at 3, 9 and 15 months after diagnosis. To test the hypotheses, multiple hierarchical regression analyses were performed.

RESULTS

Lower levels of trust were associated with more emotional distress and more physical limitations at 3, 9 and 15 months after diagnosis in more anxiously attached patients, but not in less anxiously attached patients.

DISCUSSION

These results indicate an attachment-dependent effect of trust in one's physician. Explanations and clinical implications are discussed.

The influence of medical students' and doctors' attachment style and emotional intelligence on their patient-provider communication

OBJECTIVE

Attachment style and emotional intelligence (EI) have been highlighted as potential factors influencing the variation in medical students' and doctors' patient-provider communication (PPC), particularly in relation to emotive issues. The objective of this review is to systematically review and synthesise the published literature relating to the influence of medical students' and/or doctors' attachment style and EI on their PPC.

METHODS

Electronic and hand searches were conducted to identify all published literature relating to the aim of the review. Data were narratively synthesised.

RESULTS

1597 studies were identified. 14 were included in the review, of which 5 assessed the influence of attachment style and 9 assessed the influence of EI on PPC. No studies assessed the impact of both attachment style and EI on PPC.

CONCLUSION

Whilst tentative links were found between both PPC and both attachment style and EI, heterogeneity in study design, predictor variables and outcome measures made drawing conclusions difficult.

PRACTICE IMPLICATIONS

More research is needed to assess the influence of both attachment style and EI on PPC.

Influence of psychological attachment patterns on periodontal disease - a pilot study with 310 compliant patients

OBJECTIVES

Psychosocial variables have received increased attention in periodontology. Attachment theory adds to known risk factors by linking early interactional experiences with adult tendencies of stress-regulation, health behaviour, symptom reporting, and healthcare utilization. The study investigates associations between attachment patterns and periodontal parameters.

METHODS

Within the context of a longitudinal study on periodontal diseases, 310 patients with aggressive (AgP) and chronic periodontitis (CP) filled out questionnaires on psychological attachment patterns. The influence of attachment style on health behaviour, treatment attendance and utilization, and periodontal variables was tested.

RESULTS

We found associations between psychological attachment anxiety on smoking and higher number of session use, independent of disease severity, which was more pronounced for women. Patients with higher attachment avoidance attended periodontal treatment later when diagnosed with CP and earlier with AgP. For men, we found differential associations for attachment avoidance and anxiety and number of teeth at beginning of treatment.

CONCLUSION

Psychological attachment patterns are a promising target for understanding periodontal disease in addition to known psychosocial risk factors.

Barriers to successful implementation of care in home haemodialysis (BASIC-HHD):1. Study design, methods and rationale

Background

Ten years on from the National Institute of Health and Clinical Excellence’ technology appraisal guideline on haemodialysis in 2002; the clinical community is yet to rise to the challenge of providing home haemodialysis (HHD) to 10-15% of the dialysis cohort. The renal registry report, suggests underutilization of a treatment type that has had a lot of research interest and several publications worldwide on its apparent benefit for both physical and mental health of patients. An understanding of the drivers to introducing and sustaining the modality, from organizational, economic, clinical and patient perspectives is fundamental to realizing the full benefits of the therapy with the potential to provide evidence base for effective care models. Through the BASIC-HHD study, we seek to understand the clinical, patient and carer related psychosocial, economic and organisational determinants of successful uptake and maintenance of home haemodialysis and thereby, engage all major stakeholders in the process.

Design and methods

We have adopted an integrated mixed methodology (convergent, parallel design) for this study. The study arms include a. patient; b. organization; c. carer and d. economic evaluation. The three patient study cohorts (n = 500) include pre-dialysis patients (200), hospital haemodialysis (200) and home haemodialysis patients (100) from geographically distinct NHS sites, across the country and with variable prevalence of home haemodialysis. The pre-dialysis patients will also be prospectively followed up for a period of 12 months from study entry to understand their journey to renal replacement therapy and subsequently, before and after studies will be carried out for a select few who do commence dialysis in the study period. The process will entail quantitative methods and ethnographic interviews of all groups in the study. Data collection will involve clinical and biomarkers, psychosocial quantitative assessments and neuropsychometric tests in patients. Organizational attitudes and dialysis unit practices will be studied together with perceptions of healthcare providers on provision of home HD. Economic evaluation of home and hospital haemodialysis practices will also be undertaken and we will apply scenario ("what … if") analysis using system dynamics modeling to investigate the impact of different policy choices and financial models on dialysis technology adoption, care pathways and costs. Less attention is often given to the patient’s carers who provide informal support, often of a complex nature to patients afflicted by chronic ailments such as end stage kidney disease. Engaging the carers is fundamental to realizing the full benefits of a complex, home-based intervention and a qualitative study of the carers will be undertaken to elicit their fears, concerns and perception of home HD before and after patient’s commencement of the treatment. The data sets will be analysed independently and the findings will be mixed at the stage of interpretation to form a coherent message that will be informing practice in the future.

Discussion

The BASIC-HHD study is designed to assemble pivotal information on dialysis modality choice and uptake, investigating users, care-givers and care delivery processes and study their variation in a multi-layered analytical approach within a single health care system. The study results would define modality specific service and patient pathway redesign.

Study Registration

This study has been reviewed and approved by the Greater Manchester West Health Research Authority National Research Ethics Service (NRES) The study is on the NIHR (CLRN) portfolio.