History of attachment theory
Infant attachment
Adult attachment
In the late 1980s Cindy Hazan and Phillip Shaver applied the attachment theory to adult romantic relationships based on observations of the interactions between adult romantic partners. They noticed that romantic partners often prefer to be physically close, become anxious when they are separated and that stressful situations can be buffered by the presence of a romantic partner. Three main methods of measuring adult attachment have been developed, with slightly different purposes and variable amounts of concordance between them. Some aim to categorize attachment style while others rate degrees of attachment anxiety and avoidance.Attachment styles
Attachment styles refer to characteristic patterns of thought concerning the ability of self and others to help an individual achieve security. Longitudinal studies have suggested attachment is fairly stable from childhood to adulthood. When shifts do occur, it is usually with good reason; it shifts away from secure attachment due to increased hardship and shifts towards secure related to finding partners in adulthood or finding symbolic attachments (God, places, pets, etc.).Secure
Securely attached people generally have positive views about themselves and about others. They tend to agree with statements "It is relatively easy for me to become emotionally close to others.", "I am comfortable depending on others and having others depend on me.", and "I don't worry about being alone or others not accepting me."Insecure
* '' Anxious-preoccupied'' people tend to view themselves less positively than they view others. They are more likely to become highly anxious when they are away from their attachment partners and are at risk of becoming, or seeming, dependent. They tend to agree with statements such as "I want to be completely emotionally intimate with others, but I often find that others are reluctant to get as close as I would like", and "I am uncomfortable being without close relationships, but I sometimes worry that others don't value me as much as I value them." * ''Avoidant-dismissive'' people tend to have a positive view of themselves and a less positive view of others. They often highly value independence and become uncomfortable in, or resist, situations where they become dependent on others. They tend to agree with statements such as "I am comfortable without close emotional relationships", "It is very important to me to feel independent and self-sufficient", and "I prefer not to depend on others or have others depend on me." This is considered to be roughly equivalent to the anxious-avoidant style in children. * ''Fearful-avoidant'' people tend to have conflicted, and often negative, views of themselves and of others. They often desire to have emotional relationships but feel uncomfortable when others get too close. They tend to agree with statements such as "I am somewhat uncomfortable getting close to others. I want emotionally close relationships, but I find it difficult to trust others completely, or to depend on them. I sometimes worry that I will be hurt if I allow myself to become too close to others." People with loss or trauma in childhood are at greater risk of developing this style of attachment.Insecure attachment styles in healthcare settings
* ''Anxious-preoccupied'' people with anxious-preoccupied attachment tend to be hypervigilant to signs of danger and worry or catastrophize about symptoms. In health care appointments, their narrative is full of intense negative emotion but is relatively sparse in the specific detail desired by health care providers. This presentation can readily be perceived as "needy" or "dramatic". If the healthcare provider pulls away in response it may reinforce the patient's need to articulate their distress, creating a cycle of distress-withdrawal-distress. * ''Avoidant-dismissive'' people with avoidant dismissive attachment emphasize their independence and minimizing expressing distress. They may delay seeking healthcare (see healthcare utilization), minimize reporting symptoms and disclose limited personal information. * ''Fearful-disorganized'' people with fearful attachment often avoid routine healthcare, but present in a crisis with volatile, intense, negative emotions. Due to their degree of distress, they can present a disorganized narrative that is difficult for providers to follow and interpret diagnostically.Working model
Working models are representatives of the cognitiveBartholomew and Horowitz model
Bartholomew and Horowitz proposed and verified a working model based on two dimensions; the view of the self (self-esteem) and the view of others (sociability) *Secure: Positive view of self, Positive view of other *Dismissive: Positive view of self, Negative view of other *Preoccupied: Negative view of self, Positive view of other *Fearful: Negative view of self, Negative view of otherPrototype-insecurity classification model
In 2012 Maunder and Hunter combined the internal working model with the attitudes, behaviours and emotional expression of the different styles to create a prototype based classification that included severity of insecurity. This model was designed to be clinically useful, allowing healthcare providers to identify and predict the behaviours of patients whose attachment systems were activated by pain and illness. They distinguish the different attachment styles by; 1) attachment anxiety, the discomfort someone feels when separated, 2) attachment avoidance, which is discomfort associated with closeness and 3) severity of insecurity *Secure: Low anxiety, low avoidance, low severity of insecurity *Dismissive: Low anxiety, high avoidance, moderate insecurity *Preoccupied: High anxiety, low avoidance, moderate insecurity *Fearful: High anxiety, high avoidance, high insecurity *Disorganized: High anxiety, high avoidance, high insecurity. The difference between disorganized and fearful is that people with disorganized attachment do not use a consistent strategy to find security.Attachment and health outcomes
Attachment and health interact on multiple levels. Attachment is a biologically based system tied to our response to distress and attachment styles appear to confer differences in stress physiology. Illness and pain themselves act as an "activating signal" for attachment systems, and health care providers act as attachment figures in their role addressing illness and pain. Accordingly, attachment styles influence patient perception of illness, health care utilization, medication compliance and treatment response.Physical health
While strong social support has been linked to greater resilience to stress and lower medical morbidity and mortality, the mechanism behind this association is poorly understood. In the late 1990s, Paul Ciechanowski investigated the role of attachment styles in patients managing diabetes, finding that individuals with an avoidant-dismissive style were less likely to be compliant with treatment recommendations and had less well-controlled disease as measured by glycated hemoglobin. Larger scale evidence comes from a large American survey of self-reported attachment styles and physical illness conducted by McWilliams and Bailey. They found that those with insecure attachment reported more physical illness than securely attached individuals. Specifically, they found preoccupied individuals reported more heart disease, and dismissive individuals more pain conditions. A prospective study followed children until the age of 32 and found a similar pattern of results. They found that people with anxious-resistant (dismissive) styles of attachment reported vague,Mental health
Attachment theory can be conceptualized as a theory of emotional regulation. Bowlby predicted that insecure attachment would be a risk factor for mental health difficulties based on ineffective, or overly rigid, strategies for reducing distress and maintaining psychological resilience. There is a substantial body of literature that supports an association between adult insecure attachment and a wide variety of mental health disorders including depression, anxiety, eating, psychotic and personality disorders. Prospective evidence (research starting with infant attachment and following up over time) is mostly limited to studies following infants into childhood or adolescence as opposed to adulthood, but does demonstrate that insecure attachment is a general risk factor for both internalizing and externalizing symptomatology. Of the handful of studies that have followed infants to adulthood, the only two clear relationships that exist are between (1) disorganized attachment and dissociative symptoms and (2) resistant attachment and anxiety disorders in late adolescence. Causal relationships between insecure attachment and mental illness may be complex. Some risk factors for insecure attachment such as loss of parental figure, and sexual or physical abuse, are also risk factors for mental health disorders. Self-report measures of attachment may be biased by mental health conditions. For example, clinical depression is often associated with negative thoughts about the self, and this cognitive bias may influence the self-report in attachment questionnaires. There may be interpersonal consequences from untreated mental health conditions. Pre-existing psychological problems can increase the likelihood of secure attachment changing to insecure attachment over time.Mechanisms by which attachment influences health
Maunder and Hunter outlined three ways in which insecure attachment can serve as a risk factor for health problems: 1) It may increase one's susceptibility to stress by changing stress physiology 2) It may be related to potentially harmful behaviours undertaken to regulate affect, and 3) It may change the way people interact with the healthcare systemAttachment and stress
The stress response in humans is largely governed by the hypothalamic-pituitary-adrenal axis (HPA) andHealth behaviours
According to the attachment theory, people with insecure attachments have less effective strategies for dealing with negative emotions compared to people with secure attachments. One way which insecurely-attached individuals may try to regulate their distress is by using strategies or behaviours that are attractive for their short term relief, but may have deleterious risks over years like eating, drug use or risky sex. In a survey of 356 primary care patients in Toronto, rates of smoking, harmful drinking, and obesity, were all found to be highest in those with the most severe anxious and avoidant attachment. Both attachment anxiety and attachment avoidance have been linked in separate studies to increasing the risk of eating disorders and substance use in adolescents.Eating
A review of attachment and eating disorder literature in 2010 showed rates of insecure attachment to be approximately 70% in eating disorder populations in contrast to the 30-40% prevalence in the normal population. These rates are similar to those found in other mental health populations. The review noted small trends for anxious attachment to be more highly associated with binge-purging symptomatology and avoidant attachment to be more highly associated with restrictive. The relationship between high attachment anxiety and disinhibited eating, or binge eating, has also been found in non-clinical and pre-bariatric surgery populations. The disordered eating in insecure attachment does seem to have implications for overall health as well, with one study demonstrating a relationship with higher body mass index and another demonstrating a higher risk for metabolic syndrome at midlife.Drug use
Recreational substances provide a powerful external means of regulating affect. Insecure attachment is considered to be one of the chief psychological constructs associated with increased risk for drug use. A small study in Germany found that drug users were less likely to be secure than non-drug users and that heroin users in particular had a markedly high rate of fearful attachment. Researchers believed that these findings were in keeping with the "self-medication" hypothesis of drug use and that heroine, as opposed to other drugs of abuse, may target attachment distress more readily by acting more directly on the opioid system.Sex
Risky sexual behaviour is defined as sexual contact with an increased risk of either unwanted pregnancy or sexually transmitted infection. In a study aimed at evaluating the evidence supporting six major risky sex theories, Leslie Simons and her colleagues found that only the social support and attachment theory had strong empirical support. In the attachment theory model, risk is enhanced in insecurely attached individuals due to negative working models of relationships, reduced closeness in intimate relationships and through decreased self-control. In terms of conscious motivations for sex, attachment anxiety is related to many attachment-related motivations including using sex for desire for emotional closeness, reassurance, self-esteem enhancement, stress reduction, the experience and exertion of power, elicitation of caregiving from a partner, protection from a partner's anger or bad moods. Those high in attachment avoidance report using sex for power or partner manipulation and endorse a desire to use sex as a way of avoiding emotional closeness. Accordingly, there is evidence that attachment avoidance is associated with positive attitudes towards casual sex, a higher number of casual sex partners, and an interest in emotionless sex and one-night stands.Treatment adherence
Attachment insecurity also plays an important role in how people follow the advice of the healthcare community. Attachment avoidance has consistently been linked to poorer treatment adherence and more recently to no shows in scheduled follow up appointments. Attachment avoidance has also been linked to lower rates of cervical cancer screening in both American and Iranian populations.Healthcare utilization
The attachment theory predicts that people high in attachment avoidance and people high in attachment anxiety would display different utilization of health care resources based on their prototypical behavioural responses when stressed. The theory predicts that people high in attachment avoidance, when faced with an illness, are likely to minimize their symptoms, and wait longer to see a health care provider, since they view their own distress as a sign of unacceptable vulnerability and also because their internal working model dictates that other people are not useful in helping them manage distress. For those high in attachment anxiety, they would have higher distress when faced with an illness, less perceived ability to manage it on their own, and thus visit health care services more frequently to try to attain security. For those with high anxiety and high avoidance, or fearful attachment, they would be predicted to present less frequently than those with secure attachment, but show up in a crisis when they do, which may interfere with optimal care. Research findings have generally been supportive of these predictions. One of the earliest studies in the field found correlations between preoccupied attachment and increased symptom reporting and an inverse relationship between avoidant attachment and visits to health professionals. High attachment anxiety has been associated with increased symptom reporting and visits to healthcare providers, and high attachment avoidance associated with less visits and decreased treatment complianceReferences
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