An Attachment-Based Model of the Relationship Between Childhood Adversity and Somatization in Children and Adults

[Psychocorporal approach to functional somatic disorders]

Functional somatic disorders (FSD) are common conditions that result in a significant deterioration of the quality of life. Their origin is multifactorial and poorly understood, and their management is often inadequately defined. Medications typically show limited effectiveness, while mind-body approaches play a central role, guided by three key principles: establishing an empathetic, respectful, and sincere doctor-patient relationship; promoting regular and gradual physical activity; and implementing cognitive behavioral therapy (CBT). Special attention must be devoted to establishing a trustworthy relationship between the physician and the patient. Recognizing the reality and severity of symptoms and providing a positive diagnosis as well as an explanatory model to account for them rationally are fundamental aspects of patient management. Cognitive and behavioral maintenance factors should be investigated and constitute therapeutic targets. Cognitive factors include focused attention on body functioning and catastrophizing. Patients frequently display avoidance behaviors, particularly in relation to physical exertion, and it is crucial to motivate them to reintroduce gradual physical activity customized to their abilities. This approach has demonstrated efficacy in improving fatigue, pain, and the physical and mental quality of life for patients with FSD. Among psychotherapeutic approaches, the benefit of CBT is well-established. The combination of gradual physical activity and CBT appears to be complementary. Other mind-body approaches such as mindfulness meditation might help although their level of evidence is weaker. Given the prevalence of FSD in the general population, it seems necessary for all physicians to be trained in managing this condition.

Attachment security and somatization: The mediating role of emotion dysregulation in a sample of Latinx young adults

BACKGROUND

Somatization has been linked to the underdiagnosis of mental health disorders among individuals from racial and ethnic minority groups, notably among Latinxs. While prior research has emphasized sociocultural factors, the exploration of potential inter- and intrapersonal mechanisms behind somatization remains limited.

METHODS

The current study examined the relation between attachment insecurity, emotion dysregulation, and somatization among Latinx young adults. Data were collected across seven separate Texas universities (N = 822). Most identified as female (76 %), were born in the United States (50.9 %) and were in their first or second year of university (60.6 %).

RESULTS

Hypothesis testing relied on two mediation models: maternal attachment security and paternal attachment security. The maternal attachment security model significantly predicted somatization, explaining 25 % of the variance. Notably, emotion dysregulation and maternal attachment security had main effects on somatization after accounting for country of origin, age, and gender. Results were similar for the paternal attachment security model.

LIMITATIONS

Limitations include skewed gender distribution, a non-clinical college student sample, cross-sectional design preventing causal inferences, and potential bias in self-report measures.

CONCLUSIONS

Attachment security and emotion dysregulation play an essential role in the experience of somatic symptoms among Latinx young adults. Our results suggest that health care providers take into account insecure attachment and emotion regulation history of Latinxs presenting with somatic symptoms.

A Reliability Generalization Meta-Analysis of the Mother-To-Infant Bonding Scale

The Mother-to-Infant Bonding Scale (MIBS) is among the most popular measurement tools to evaluate caregiver-infant attachment. We carried out a meta-analysis study to explore the generalizability of the reliability coefficients for the MIBS in different studies. The literature review yielded a total of 702 studies investigating caregiver-infant attachment. After removing duplicate studies, we also excluded compilations, meta-analyses, qualitative studies, those using different measurement tools, studies published in a language other than English, citations, and those whose full texts could not be accessed. Eventually, we considered a total of 26 studies with 33 Cronbach's alpha coefficients that satisfied the inclusion criteria. We normalized the alpha coefficients using Bonett's transformation, and the analyses were performed using a 95% confidence interval. The findings revealed a Cronbach's alpha (n = 33) coefficient of 0.73 (CI = 0.68-0.77); hence, the present reliability generalization study provides evidence that the reliability scores produced after measurements with the MIBS in previous studies are acceptable across samples. Overall, further studies may reliably utilize the MIBS to evaluate mother-infant attachment.

Attachment expectations moderate links between social support and maternal adjustment from 6 to 18 months postpartum

Significant links exist between one's perception of available social support and mental health outcomes, including during the transition to motherhood. Yet, attachment theory posits that individuals do not benefit equally from social support. As such, we examined the influence of attachment representations (i.e., secure base script knowledge) as they potentially moderate links between social support and psychological distress in a 1-year longitudinal study of an ethnically diverse (56% White) sample of infant-mother dyads. We hypothesized that higher social support would predict lower maternal psychological distress and this relation would be strongest in those with higher secure base script knowledge. Results indicated that maternal perceptions of social support were significantly negatively correlated with psychological distress. Analyses revealed that secure base script scores significantly moderated these associations. Interestingly, for those high in script knowledge, low social support predicted greater psychological distress. For those low in script knowledge, social support was unrelated to psychological distress. This pattern suggested that those who expect care (i.e., high secure base script knowledge) but receive minimal support (i.e., low perceived social support) find motherhood uniquely dysregulating. Practitioners may do well to examine individuals' attachment expectations in relation to their current social support.

The Attachment Mapping Protocol (AMP): An Assessment and Treatment Tool for General Psychotherapy, Systemic Family Therapy and Multifaith Spiritual Care

This paper introduces the Attachment Mapping Protocol (AMP), which is an assessment and treatment tool for use in individual psychotherapy, systemic family therapy and multifaith spiritual care, using a bio-psycho-social-spiritual model of care. Attachment theory has a long and significant history in psychology, with an evolving relationship within the above clinical domains. A central aim of this paper will be to recognize and affirm the extension of attachment theory beyond the traditional parameters of nascent parental, guardianship bonds and individual, developmental psychology, to reveal a much broader spectrum of valid attachment considerations for mental health and spiritual well-being. A case study will be applied to the interviewing instrument to demonstrate its utility for broadening assessment beyond attachment figures to include surrogate attachments of other persons, places and things. A model of spiritual discernment derived from the Spiritual Exercises of Ignatius of Loyola will undergird this larger worldview of attachment considerations.

Management perspectives from patients with fibromyalgia experiences with the healthcare pathway: a qualitative study

Background

Fibromyalgia is a prevalent condition affecting 1-2% of the general population and can result in significant disability. Physicians and patients frequently encounter challenges in managing this condition.

Aim

The aim of this study was to explore novel management approaches through a qualitative analysis of the doctor-patient relationship.

Design and setting

Telephonic interviews were conducted with fibromyalgia patients to investigate their healthcare experiences.

Methods

Qualitative analysis was performed on patients' narratives using interpretative phenomenological analysis, a methodology that delves into each individual's subjectivity.

Results

A total of 19 adult patients with fibromyalgia, primarily middle-aged women (84% women, mean age 49.8 years), recruited from two university centers in Paris, were included in the study. The narratives of participants revealed substantial suffering and considerable functional impairment, which is paradoxical for a condition often considered benign. They reported an ongoing sense of loss of control, exacerbated by an imbalanced patient-doctor relationship. Patients constantly feared not being heard or believed, and they frequently sought attention from their caregivers. Most participants displayed significant ambivalence toward the nature of their condition and actively sought causal links. Patients' adaptive strategies sometimes worsened their symptoms, as in the case of muscular deconditioning. The healthcare system appeared deficient in managing these patients, characterized by a lack of health professional training, frequent inappropriate responses from healthcare providers, and stigmatization of psychological conditions.

Conclusion

Despite its perceived benign nature, fibromyalgia should be regarded as a severe condition due to its substantial long-term consequences. Participants reported a challenging experience with the doctor-patient relationship, marked by a strong sense of dependence and a lack of recognition. The care pathway for these patients appeared unsuitable and disorderly, potentially resulting in iatrogenic consequences. The management of patients with fibromyalgia should be enhanced and directed toward a patient-centered approach. The study provides practical recommendations regarding communication methods and patient care.

Lifeboat ethics, risk, and therapeutic opportunity: an appeal for equitable psychedelic therapy access in the "high-risk" addiction patient

Psychedelic-assisted treatment (PAT) for mental health is in renaissance. Psilocybin and MDMA stand near FDA approval, and US cities and states are decriminalizing or regulating the non-clinical use of psilocybin. However, neither FDA indications nor a regulated use model sufficiently address the complex needs and opportunities for an improved treatment of addiction. When paired with disability and social dispossession, addiction increasingly burdens informal care networks, public safety, and particularly healthcare systems. Stigma and mistreatment alienate people from opportunities for care and multiply the costs of providing care. This dynamic worsens socially determined resource limitations, enforcing stark ethical choices and perpetuating socioeconomic inequities, isolation, mental illness, medical illness, overdose, suicide, and violence. In order for psychedelic treatments to achieve their greatest utility to population health, we must intentionally develop regulatory, clinical, and payment systems supporting clinical research, rigorous safety monitoring, and implementation to address these immense needs and reduce the barriers to engagement for those who now bear the costs, including those who work at the front lines of addiction care. To achieve full fruition, I advocate for a collaborative approach, built from within networks of mutual social support but linked and accountable to public institutions charged with the equitable dissemination of these therapies for the greatest social and health equities. Rather than relegating PAT to the needs of the commercially insured or wellness markets, this is the moment to learn from ancient traditions of ritualized sacramental use, organized around faith in our mutual dependency and accountability, and to capture an opportunity to improve population health and equity. To miss this opportunity is to accept the status quo in the midst of a growing emergency, for lack of moral vision and intention to change our habits.

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OBJECTIVES

To assess the diagnosis of somatic symptom disorder (SSD) in patients with unexplained neurological symptoms occurring after SARS-CoV-2 infection, also referred to as long COVID.

DESIGN

Single-centre observational study.

PARTICIPANTS

Adult patients experiencing unexplained long-lasting neurological symptoms after mild COVID. Of the 58 consecutive patients referred in our centre, 50 were included.

INTERVENTION

Patients were contacted for a standardised psychometric evaluation by phone, followed by a self-survey.

MAIN OUTCOME

Positive diagnosis of SSD according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5).

RESULTS

Although the patients did not meet the DSM-5 criteria for a functional neurological symptom disorder specifically, SSD diagnosis based on DSM-5 criteria was positive in 32 (64%) patients. In the remaining 18 patients, SSD was considered possible given the high score on diagnostic scales. Physical examination were normal for all. Brain MRI showed unspecific minor white matter hyperintensities in 8/46 patients. Neuropsychological assessment showed exclusively mild impairment of attention in 14 out of 15 tested patients, in discrepancy with their major subjective complaint. Forty-five (90%) patients met criteria for Chronic Fatigue Syndrome. Seventeen (32%) patients were screened positive for mood-anxiety disorders, 19 (38%) had a history of prior SSD and 27 (54%) reported past trauma. Additional self-survey highlighted post-traumatic stress disorder in 12/43 (28%), high levels of alexithymia traits and perfectionism. Long-lasting symptoms had a major impact with a high rate of insomnia (29/43, 67%), psychiatric follow-up (28/50, 56%) and work or pay loss (25/50, 50%).

CONCLUSION

A majority of patients with unexplained long-lasting neurological symptoms after mild COVID met diagnostic criteria for SSD and may require specific management.

TRIAL REGISTRATION NUMBER

NCT04889313.

Families With Violence Exposure and the Intergenerational Transmission of Somatization

INTRODUCTION

Adults who have histories of childhood trauma have been noted to display greater somatization, dissociative symptoms and affect dysregulation. What happens in the parent-child relationship when those traumatized children become parents? A potential link to somatization in the child has been suggested by several prior studies. Children who have early attachment disturbances had more physical complaints if their mothers displayed less maternal sensitivity during observed parent-child interactions. Yet, the intergenerational link between maternal and child somatization has not been sufficiently explored in a longitudinal study in order to understand the potential impact of maternal trauma history and related psychopathology on subsequent child somatization and psychopathology.

METHODS

This paper examined prospective, longitudinal data of 64 mother-toddler dyads (mean age = 2.4 years, SD = 0.7) who were later studied when children had a mean age of 7 years. Mothers with and without histories of interpersonal violence (IPV; physical/sexual abuse and/or family violence exposure) were included. Mothers with IPV histories were oversampled. Linear and Poisson regression models were used to test the associations between maternal IPV-related post-traumatic stress disorder (PTSD) with maternal somatization severity when children were toddlers, and between maternal somatization and maternal interactive behaviors with child somatization by maternal report and clinician-rated assessment at school-age.

RESULTS

Maternal PTSD severity was significantly associated with increased maternal somatization severity (p = 0.031). Maternal somatization severity during the child's early childhood predicted both maternal report of child somatization (p = 0.011) as well as child thought problems (p = 0.007) when children were school-aged. No association was found between maternal somatization and child-reported psychopathology. The study did not find that maternal alexithymia, caregiving behaviors or child exposure to violence contributed significantly to the model examining the association between maternal and child somatization.

CONCLUSION

The results are in line with the hypothesis of intergenerational transmission of somatization in the context of IPV and related maternal PTSD during formative early development. We interpret this as an expression of psychological distress from mother to child, as maternal trauma and pathology affect the caregiving environment and, thus, the parent-child relationship. The authors conclude with a discussion of implications for parent-infant and early childhood intervention.

Immune and Epigenetic Pathways Linking Childhood Adversity and Health Across the Lifespan

Childhood adversity is associated with a host of mental and physical health problems across the lifespan. Individuals who have experienced childhood adversity (e.g., child abuse and neglect, family conflict, poor parent/child relationships, low socioeconomic status or extreme poverty) are at a greater risk for morbidity and premature mortality than those not exposed to childhood adversity. Several mechanisms likely contribute to the relationship between childhood adversity and health across the lifespan (e.g., health behaviors, cardiovascular reactivity). In this paper, we review a large body of research within the field of psychoneuroimmunology, demonstrating the relationship between early life stress and alterations of the immune system. We first review the literature demonstrating that childhood adversity is associated with immune dysregulation across different indices, including proinflammatory cytokine production (and its impact on telomere length), illness and infection susceptibility, latent herpesvirus reactivation, and immune response to a tumor. We then summarize the growing literature on how childhood adversity may alter epigenetic processes. Finally, we propose future directions related to this work that have basic and applied implications.

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.

Attachment Style Mediates the Relationship between Trauma and Somatic Distress among Individuals with Serious Mental Illness

Objective: Individuals with mental illnesses severe enough to require psychiatric hospitalization often have significant trauma histories, have developed maladaptive attachment styles, and experience comorbid somatic distress. Gaining an understanding about the interaction of such factors may lead to prioritizing interventions that target factors that mediate the relationship between trauma and adverse somatic distress. Prior research has examined various mediation models, but results have been mixed and conducted only on outpatient samples.Method: Participants (47.7% female) in a large sample (N = 2702) with a mean age of 34.62 (SD = 14.7) were enrolled in a specialist inpatient program and completed self-report measures pertaining to demographics, attachment insecurity, lifetime trauma exposure, and somatic distress within 72 hours of admission. The dimensions of attachment insecurity (i.e., attachment anxiety and attachment avoidance) were tested as parallel mediators in the relationship between lifetime trauma exposure and somatic distress.Results: The mediation analyses revealed that attachment anxiety and avoidance partially mediated the relationship between lifetime trauma exposure and somatic distress.Conclusions: These results are the first to date to implicate both attachment anxiety and avoidance as mediators between trauma exposure and somatic distress in a high acuity sample. Although the results do not imply causality, they do call attention to social-cognitive factors related to somatic distress and highlight the importance of considering attachment styles as a possible contributor to comorbid physical symptoms in patients with trauma exposure.

Physicians' knowledge and practices regarding screening adult patients for adverse childhood experiences: a survey

Background

Adverse Childhood Experiences (ACEs) are common and associated with many illnesses. Most physicians do not routinely screen for ACEs. We aimed to determine if screening is related to knowledge or medical specialty, and to assess perceived barriers.

Methods

Physicians in Ontario, Canada completed an online survey in 2018–2019. Data were analyzed in 2019.

Results

Participants were 89 family physicians, 46 psychiatrists and 48 other specialists. Participants screened for ACEs “never or not usually” (N = 58, 31.7%), “when indicated” (N = 67, 36.6%), “routinely” (N = 50, 27.3%) or “other” (N = 5, 2.7%). Screening was strongly associated with specialty (Chi² = 181.0, p < .001). The modal responses were: family physicians - “when indicated” (66.3%), psychiatrists - “routinely” (91.3%), and other specialists - “never or not usually” (77.1%). Screening was not related to knowledge of prevalence of ACEs, or of the link between ACEs and mental health, but was significantly associated with knowing that ACEs are associated with physical health. Knowing that ACEs are linked to stroke, ischemic heart disease, COPD, and diabetes predicted greater screening (Chi² 15.0–17.7, each p ≤ .001). The most prevalent perceived barriers to screening were lack of mental health resources (59.0%), lack of time (59.0%), concern about causing distress (49.7%) and lack of confidence (43.7%).

Conclusions

Enhancing knowledge about ACEs’ negative influence on physical illness may increase screening. Efforts to promote screening should address concerns that screening is time-consuming and will increase referrals to mental health resources. Education should focus on increasing confidence with screening and with managing patient distress.

Associations among parental and romantic attachment, personality disorder symptoms, and physical health

The relations of parental and romantic attachment with physical health symptoms and the mediating role of personality disorder symptoms in those relations were examined in an online survey of US young adults. Latent class analysis identified two groups: occasionally sick and healthier. Insecure attachment was related to being occasionally sick and to personality disorder symptoms (poor reality testing, primitive defenses, and diffused identity). Primitive defenses/identity diffusion mediated relations between insecure parental attachment and physical symptoms. Maternal and paternal attachment each provided unique information about these relations. Romantic attachment was not associated with physical symptoms after adjusting for parental attachment and personality disorder symptoms.

Systematic Review: Feasibility, Reliability, and Validity of Maternal/Caregiver Attachment and Bonding Screening Tools for Clinical Use

INTRODUCTION

Infant-caregiver attachment is crucial for an infant's immediate and long-term social-emotional development and health. Despite advocacy by the National Institute of Children's Health Quality for infant social-emotional development screening, there is a lack of identified tools for use in primary care. Therefore, we conducted a systematic review to identify caretaker-infant attachment self-report screening tools that would be feasible, reliable, and valid for use in primary care.

METHOD

A systematic search identified 340 abstracts/articles, which were screened using inclusion and exclusion criteria. Twelve articles and six self-report attachment tools were examined for reliability, validity, and feasibility characteristics.

RESULTS

Six caregiver-infant attachment self-report tools were identified. Establishment of feasibility, reliability, and validity are in the early stages.

DISCUSSION

Potential infant-caretaker attachment screening tools were identified for use in primary care practices. Suggestions for research and practice include informal screening, additional psychometric testing, and development of policies supporting implementation of screening.

Emotions, Bodily Changes, and the Social Environment: How Did Early Psychosomatic Medicine Consider the Social Dimension in Health and Disease?

OBJECTIVE

Social relationships play an important role in human health and disease processes, and the field of psychosomatic medicine currently integrates social factors in its theoretical models and clinical interventions. This article provides a historical perspective on the field of psychosomatic medicine in the United States and examines the extent to which early American psychosomatic medicine incorporated the impact of social relationships on health and disease outcomes.

METHODS

We searched PubMed across all issues of Psychosomatic Medicine for key words related to emotions versus social processes. Article counts are compared for these key words. We then performed a narrative review to analyze how concepts of associations among emotional, interpersonal, and physiological variables evolved in early publications.

RESULTS

Of 5023 articles found in Psychosomatic Medicine, 1453 contained an emotional, 936 a social search term, and 447 contained both. In the qualitative review, influences of the social environment on emotional states and physiology were recognized already in the 1930s but they only played a subordinate role in early Psychosomatic Medicine. Publications often lacked a clear working model how interpersonal events exert their impact on physiology. With increasing understanding of developmental and neural mechanisms, a more differentiated view evolved.

CONCLUSIONS

Early publications in psychosomatic medicine mainly focused on associations between emotions and physiology. However, some highlighted the importance of interpersonal and social factors. Later, the understanding of emotions, social relationships, and physiology with their developmental and neurobiological correlates have led to a fuller "biopsychosociocultural" understanding of health and disease, although more research on and within these networks is urgently needed.

Biased Competition Favoring Physical Over Emotional Pain: A Possible Explanation for the Link Between Early Adversity and Chronic Pain

BACKGROUND

Early adversity predisposes to chronic pain, but a mechanistic explanation is lacking. Survivors of early adversity with chronic pain often seem impaired in their ability to be aware of, understand, and express distressing emotions such as anger and fear in social contexts. In this context, it has been proposed that pain may at times serve as a "psychic regulator" by preventing awareness of more intolerable emotions.

METHOD

This narrative review builds on the premise that physical pain and emotional pain are conscious experiences that can compete for selective attention. We highlight mechanisms whereby the consequences of early adversity may put emotional pain at a competitive disadvantage. A case history, supportive research findings, and an evidence-based neurobiological model are presented.

RESULTS

Arising from abuse or neglect in childhood, impairments in the adult capacity to attend to and/or conceptualize the emotional meaning of felt distress may be associated with impaired engagement of the default network and impaired top-down modulation of affective response generation processes. Persistent and poorly conceptualized affective distress may be associated with reduced emotion regulation ability, reduced vagal tone, increased inflammation, and amplified nociceptive signals. Attention to physical pain may be reinforced by the temporary reduction in negative emotions that it causes.

CONCLUSIONS

These processes jointly promote biased competition favoring attention to physical pain and away from one's own emotions. They may constitute an unintentional analog of the phenomenon of self-injury in patients with borderline personality disorder in whom the intentional infliction of physical pain serves to downregulate intense emotional distress. Attending to, expressing, and understanding previously unacknowledged psychological distress unrelated to pain may facilitate recovery from chronic pain after early adversity. Mechanistic studies that can validate this clinically derived neurobiological hypothesis are urgently needed.

Examining the relationships between childhood abuse history, attachment, and health anxiety

This study examined the relationship between childhood abuse experiences and health anxiety in adulthood and investigated the role of attachment in this relationship. In total, 181 university students (aged 18–29 years) completed a battery of measures that assessed childhood abuse, health anxiety, and attachment orientation. Health anxiety was associated with all categories of childhood abuse and overall childhood abuse severity. Anxious attachment partially mediated the relationship between overall childhood abuse and health anxiety in adulthood. The results further our understanding of the relationship between childhood abuse and health anxiety in adulthood and provide support for the interpersonal model of health anxiety.

Management of somatic symptom disorder

This review paper gives an overview of the management of somatic symptom disorder. It starts with a description of the clinical problem of patients with persistent bodily distress, discusses classificatory, epidemiological, and etiological issues and then describes the evidence and practical principles of dealing with these patients who are often seen as "difficult" to treat. It is concluded that the best-suited approach is stepped care with close cooperation of primary care, a somatic specialist, and mental health care professionals operating on the basis of a biopsychosocial model of integrating somatic as well as psychosocial determinants of distress and therapeutic factors.

Insecure Attachment and Hypothalamus-Pituitary-Adrenal Axis Functioning in People With Eating Disorders

OBJECTIVE

Childhood attachment experiences affect adult emotion regulation and ability to cope with stressors. Therefore, insecure attachment may influence the functioning of the hypothalamic-pituitary-adrenal (HPA) axis and a dysregulation of HPA axis has been found in insecure attached healthy individuals. The effects of attachment on HPA axis activity have never been investigated in eating disorders (EDs). Therefore, we assessed the relationships between insecure attachment and the cortisol awakening response (CAR) in adults with EDs.

METHODS

Seventy-eight patients with EDs (43 with anorexia nervosa, 35 with bulimia nervosa) were recruited. They completed the Experience in Close Relationships questionnaire, which provides a rating of two insecure attachment dimensions (anxiety and avoidance) and collected saliva samples to measure the CAR. Differences in the CAR between groups with high and low attachment anxiety and between groups with high and low attachment avoidance were evaluated by repeated measures two-way analysis of variance.

RESULTS

Patients with high attachment anxiety showed a reduced CAR compared with those with low attachment anxiety (F1,76 = 7.31, p = .008). The CAR did not differ between the groups with high and low attachment avoidance (F1,76 = 0.01, p = .93). Patients with high levels of insecure attachment showed a more severe eating-related psychopathology.

CONCLUSIONS

Our data show, for the first time, a specific association of the anxious attachment with the HPA axis activity in EDs and suggest a possible role of attachment in the biological vulnerability to stress of adult patients with EDs.

Management of Functional Somatic Syndromes and Bodily Distress

Functional somatic syndromes (FSS), like irritable bowel syndrome or fibromyalgia and other symptoms reflecting bodily distress, are common in practically all areas of medicine worldwide. Diagnostic and therapeutic approaches to these symptoms and syndromes vary substantially across and within medical specialties from biomedicine to psychiatry. Patients may become frustrated with the lack of effective treatment, doctors may experience these disorders as difficult to treat, and this type of health problem forms an important component of the global burden of disease. This review intends to develop a unifying perspective on the understanding and management of FSS and bodily distress. Firstly, we present the clinical problem and review current concepts for classification. Secondly, we propose an integrated etiological model which encompasses a wide range of biopsychosocial vulnerability and triggering factors and considers consecutive aggravating and maintaining factors. Thirdly, we systematically scrutinize the current evidence base in terms of an umbrella review of systematic reviews from 2007 to 2017 and give recommendations for treatment for all levels of care, concentrating on developments over the last 10 years. We conclude that activating, patient-involving, and centrally acting therapies appear to be more effective than passive ones that primarily act on peripheral physiology, and we recommend stepped care approaches that translate a truly biopsychosocial approach into actual management of the patient.

Alexithymia in Gastroenterology and Hepatology: A Systematic Review

Background: Alexithymia is a multifaceted personality construct that represents a deficit in the cognitive processing of emotions and is currently understood to be related to a variety of medical and psychiatric conditions. The present review aims to investigate the relationship of alexithymia with gastrointestinal (GI) disorders as functional gastrointestinal disorders (FGID, as irritable bowel syndrome (IBS) and functional dyspepsia) and inflammatory bowel disease (IBD) [ulcerative colitis (UC) and Crohn's disease (CD)] and liver diseases as chronic hepatitis C (CHC), cirrhosis, and liver transplantation. Methods: The articles were selected from the main electronic databases (PsycInfo, Medline, PubMed, Web of Science, Scopus, Cochrane, and ScienceDirect) using multiple combinations of relevant search terms (defined GI and liver diseases, articles in English, use of the Toronto scales [TAS] for alexithymia). The TAS was selected as inclusion criterion because it is the most widely used measure, thus allowing comparisons across studies. Results: Forty-eight studies met the inclusion criteria, of which 38 focused on GI disorders (27 on FGID and 11 on IBD) and 10 on liver diseases. Most studies (n = 30, 62%) were cross-sectional. The prevalence of alexithymia was higher in FGID (two third or more) than IBD and liver diseases (from one third to 50% of patients, consistent with other chronic non-GI diseases) than general population (10-15%). In functional disorders, alexithymia may be viewed as a primary driver for higher visceral perception, symptom reporting, health care use, symptom persistence, and negative treatment outcomes. Also, it has been found associated with psychological distress and specific GI-related forms of anxiety in predicting symptom severity as well as post-treatment outcomes and is associated with several psychological factors increasing the burden of disease and impairing levels of quality of life. A number of critical issues (small sample sizes, patients referred to secondary and tertiary care centers, cross-sectional study design, use of one single scale for alexithymia) constitutes a limitation to the generalization of findings. Conclusions: Alexithymia showed to play different roles in gastroenterology according to the clinical characteristics and the psychological burden of the various disorders, with main relevance in increasing subjective symptom perception and affecting negatively post-treatment outcomes.

Health anxiety and associated constructs in children and adolescents with congenital heart disease: A CHAMPS cohort study

This study explored health anxiety and associated constructs in children and adolescents with congenital heart disease and typically developing children and adolescents. A total of 84 participants (7-16 years) completed measures of health anxiety, intolerance of uncertainty, anxiety sensitivity, and DSM-IV anxiety disorder symptom categories. Results demonstrated that children and adolescents with congenital heart disease experienced significantly higher levels of health anxiety and associated constructs compared to typically developing children and adolescents. Our findings highlight a specific chronic physical health population who may be at risk of clinical levels of health anxiety and related psychopathology and require appropriate intervention.

Research on Somatization and Somatic Symptom Disorders: Ars longa, vita brevis

The new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition defines somatic symptom and related disorders as long-standing somatic symptoms that are associated with disproportionate thoughts, feelings, and behaviors, irrespective of whether or not a medical cause for these symptoms can be determined. In this Special Section of Psychosomatic Medicine, several articles address diagnostic issues and the central nervous system correlates of somatic symptom and related disorder and document new developments in its treatment.