A Prototype-Based Model of Adult Attachment for Clinicians

Adult attachment insecurity and responses to prolonged severe occupational stress in hospital workers during the COVID-19 pandemic

Background

The stress response includes appraisal of the threat and one’s resources, coping (including interpersonal interactions), distress, and recovery. Relationships between patterns of adult attachment and stress response have received little study in the context of prolonged, severe occupational stress, limiting knowledge about how attachment patterns contribute to occupational burnout and recovery.

Aim

This study aimed to assess the relationship of adult attachment to aspects of the stress response over time in hospital workers during a pandemic.

Methods

This study included 538 hospital workers within a general and a rehabilitation hospital in Toronto, Canada between September 2020 and November 2021. Half, selected at random, completed validated measures of adult attachment, resilience, self-efficacy, coping, interpersonal problems, and various stress outcomes. Attachment insecurity severity was calculated as the vector addition of attachment anxiety and attachment avoidance. Correlations between these measures were determined at individual time-points and temporal patterns of adverse outcomes using repeated-measures ANOVA.

Results

All correlations between measures of attachment and resilience or self-efficacy were significant and moderately strong (r = .30–.48), while most correlations with coping strategies were weak (<.20). Attachment avoidance was more strongly correlated with interpersonal problems related to being cold, whereas attachment anxiety was more strongly correlated with problems related to being intrusive, overly-nurturant, exploitable and non-assertive. Attachment insecurity severity was moderately correlated with every dimension of interpersonal problems. A significant main effect of each attachment measure on each stress outcome was found (effects sizes: .18–.26). Attachment insecurity severity was significantly associated with outcome X time interactions for burnout, consistent with greater resilience for those with lower attachment insecurity.

Conclusions

Severity of insecure attachment was correlated with each measure of self-appraisal, interpersonal problems, and all measured stress outcomes. Severity of attachment insecurity performed well as a summary attachment measure. Greater security is associated with patterns of recovery that indicate resilience.

Associations of Childhood Maltreatment and Attachment Styles with Romantic Breakup Grief Severity: The Role of Emotional Suppression

Childhood maltreatment (CM) and insecure attachment styles may partly explain grief severity following romantic breakup. Empirical studies examining the factors that could possibly explain this association, however, remain sparse. The present study tested whether the relations among CM, attachment styles, and romantic breakup grief severity could be explained by emotional suppression in Iranian college students. In a cross-sectional study, 239 Iranian college students (ages 18-45; M = 24.11, SD = 15.29; 50.6% women) with a recent romantic breakup experience were recruited from University of Tabriz. Participants completed a diagnostic interview and self-report battery, including the Persian version of the Child Abuse Self-Reported Scale, Revised Adult Attachment Scale, Romantic Breakup Grief Inventory, and Weinberger Adjustment Inventory. Structural equation modeling was used to empirically explore the relations among variables. Results indicated that those who reported higher levels of CM also reported higher levels of romantic breakup grief. Attachment closeness showed a significant negative and direct effect on romantic breakup grief severity. However, attachment anxiety was positively associated with greater levels of romantic breakup grief. Bootstrapping results showed that CM might affect romantic breakup grief severity via emotional suppression. Furthermore, attachment closeness and attachment anxiety exerted indirect effects on romantic breakup grief severity through emotional suppression. Clinical and empirical implications are discussed.

A psychometric evaluation of the tripartite attachment battery

The Tripartite Attachment Battery (TAB) includes scales assessing attachment security, organized insecurity (i.e., anxiety and avoidance), and disorganized attachment. This recently developed series of measures provides expanded options for assessing attachment characteristics (e.g., a scale that directly assesses attachment security) and may improve the assessment of attachment anxiety and avoidance by including items capturing the secondary attachment strategies associated with them (viz., hyperactivation and deactivation). The present study utilized a community sample (N = 386) to evaluate and refine these scales. Factor analyses were conducted to: (a) examine the dimensionality of each TAB scale, and (b) guide the creation of empirically-derived subscales. The Secure Attachment Scale and the Organized Insecurity Scale were multidimensional. The Disorganized Attachment Scale was unidimensional. Most of the empirically-derived measures had internal consistency and test-retest reliability levels in the range considered adequate or better. Their correlations with a measure of psychopathology provided preliminary support for their construct validity. The TAB scales are promising measures of adult attachment characteristics. Further investigation of their psychometric properties is warranted.

The role of attachment avoidance: A longitudinal mediation model predicting existential distress in patients with advanced cancer

OBJECTIVE

Although a protective effect of reliable interpersonal relationships on existential distress has been established, evidence remains inconclusive for attachment insecurity as an underlying factor of persistent psychological distress. We tested a longitudinal model hypothesizing attachment avoidance as a mediator of high demoralization and anxiety over time.

METHODS

We studied 206 patients with advanced cancer (mean age = 59.6, 61% female) participating in an intervention trial. Patients completed self-report measures for demoralization, anxiety, perceived relatedness, attachment insecurity, and death anxiety. Our mediated path model included perceived relatedness and death anxiety at baseline as predictors, attachment avoidance at baseline as mediator, and demoralization and anxiety at 6-month follow-up (N = 125) as outcomes.

RESULTS

Attachment avoidance partially mediated the relationship between death anxiety and demoralization (β = 0.07, 95% CI 0.02-0.12) and anxiety (β = 0.05, 95% CI 0.001-0.10). Findings for perceived relatedness were less conclusive. Its indirect effects through attachment avoidance were significant for both outcomes (demoralization: β = -0.07, 95% CI -0.13 to -0.02, anxiety: β = -0.05, 95% CI -0.11 to -0.003).

CONCLUSIONS

Due to its trait-like quality, attachment avoidance may play a less central role in explaining the course of existential distress over time than previous research indicated. Addressing change-sensitive relational concerns in psychosocial interventions may be more effective to alleviate existential distress.

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.

Relationships between patients' attachment characteristics and views and use of psychiatric treatment

This study explored the influence of attachment on psychiatric treatment by considering attitudes towards and the use of psychotropic medication and psychotherapy in patients with depressive and anxiety disorders. Adults referred to a psychiatrist completed self-report measures and participated in a diagnostic interview based on DSM-IV criteria. Those with depressive, anxiety or adjustment disorders were included (n = 124). Patients reported the types and dosage of current psychotropic medication as well as number of different psychiatrists and psychologists/counselors they had seen in the past 10 years. Multiple regression analyses were used to examine relationships between attachment anxiety and avoidance and the variables capturing treatment use and attitudes towards treatments. Attachment anxiety was positively associated with the number of current psychiatric medications and with both the number of psychiatrists and the number of psychologists/counselors seen. Attachment avoidance was negatively associated with the number of current psychotropic medications and beliefs about the efficacy of psychotherapy. The findings suggest that patients' attachment characteristics play a role in their views and choices regarding treatments. Developing treatments sensitive to the needs of insecurely attached individuals may lead to improved treatment outcomes.

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.

Attachment style and emotional eating in bariatric surgery candidates: The mediating role of difficulties in emotion regulation

OBJECTIVE

Difficulties with emotion regulation is a hypothesized mechanism through which attachment insecurity may affect emotional eating. No studies have yet investigated this effect in the bariatric population. Because many obese individuals engage in emotional eating, difficulty regulating emotion may be an important underlying mechanism through which attachment insecurity is linked to emotional eating in bariatric surgery candidates.

METHODS

In this cross-sectional study, 1393 adult bariatric surgery candidates from the Toronto Western Hospital were recruited to complete the Emotional Eating Scale (EES), Patient Health Questionnaire-9 (PHQ9), Generalized Anxiety Disorder-7 (GAD7), Difficulties in Emotion Regulation Scale (DERS), Eating Disorder Examination Questionnaire (EDE-Q), and the Experiences for Close Relationships 16-item Scale (ECR-16) in order to explore the mediating role of emotion regulation on the relationship between attachment insecurity and emotional eating. Path analysis within a structural equation modeling framework examined direct and indirect effects of attachment insecurity on emotional eating.

RESULTS

The indices of this overall model indicated that the specified set of direct and indirect pathways and corresponding correlations were a good fit with the data (RMSEA<.06, CFI=1.00; SRMR<.08). Moreover, tests of all of the possible indirect pathways between attachment style and emotional eating were significant.

DISCUSSION

Findings suggest that difficulties in emotion regulation may be an important mechanism to consider when examining the association between attachment insecurity and emotional eating in adult bariatric surgery candidates. Although causality cannot be concluded, these results shed light on the important role that emotion regulation may have in predicting problematic eating in bariatric patients.

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.

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.

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.

Alexithymia and adult attachment representations: associations with the five-factor model of personality and perceived relationship adjustment

Several studies have demonstrated associations between alexithymia, adult attachment styles, personality traits, and relationship adjustment. Only two studies, however, have explored associations between alexithymia and attachment representations. As part of a larger investigation of maternal and infant attachment, the current study explored this association in a sample of 97 pregnant women; in addition, measures of alexithymia and domains of the five-factor model (FFM) of personality were compared in predicting attachment security, assessed with the Adult Attachment Interview Coherence of Mind mind scale, and perceived relationship adjustment. Alexithymia negatively predicted coherence of mind; the domains of the FFM did not add significantly to the prediction. The Openness-to-Experience domain predicted relationship adjustment better than alexithymia. Contrary to findings from studies that assessed adult attachment styles, coherence of mind was unrelated to relationship adjustment and the FFM. The results suggest that alexithymia does not uniquely predict relationship adjustment beyond the domains of the FFM.

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.