Attachment and Health

From Wikipedia, the free encyclopedia
Jump to navigation Jump to search

Attachment and Health is psychological model which considers how attachment theory pertains to people’s preferences and expectations for the proximity of others when faced with stress, threat, danger or pain.[1] In 1982 the American Psychiatrist, Lawrence Kolb, noticed that patients with chronic pain displayed behaviours with their healthcare providers akin to what children might display with an attachment figure, thus marking one of the first applications of attachment theory to physical health.[2] Development of adult attachment theory and adult attachment measures in the 1990s provided researchers with the means to apply attachment theory to health in a more systematic way.[3] Since that time it has been used to understand variation in stress response, health outcomes and health behaviour. Ultimately, the application of attachment theory to health care may enable health care practitioners to provide more personalized medicine by creating a deeper understanding of patient distress and allowing clinicians to better meet their needs and expectations.

History of Attachment Theory[edit]

Infant attachment[edit]

John Bowlby and Mary Ainsworth developed attachment theory in the 1960s while investigating the effects of maternal separation on infant development.[4] The development of the Strange Situation task in 1965 by Ainsworth and Wittig allowed researchers to systematically investigate the attachment system operating between children and their parents.[5] The Strange Situation involves separating infant-parent dyads and observing infant behaviours upon reunion. Infant behaviour tended to follow patterns, leading to the development of three attachment categories: Secure, Anxious-Avoidant, and Anxious-Resistant. In 1990, Ainsworth added a new category, championed by Mary Main, called Disorganized/Disoriented attachment, characterized by its less reliable pattern of behaviour.[6]

Bowlby believed attachment to be a primary biological drive to achieve proximity with a caregiver that transforms across child development to also encompass a psychological drive to find security by achieving a preferred interpersonal distance with an important caregiver he called an attachment figure.[4] Insecure attachment patterns develop when caregivers are experienced as inconsistent or unpredictable, which necessitates the development of different strategies to achieve a sense of comfort and safety within an interpersonal setting. Furthermore, he posited that attachment figures function as a secure base that facilitate environmental eexploration and that attachment behaviours are triggered by perceived stress, danger or pain, and are thus state dependent.[7]

Adult attachment[edit]

In the late 1980s Cindy Hazan and Phillip Shaver applied 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 (see attachment measures), with slightly different purposes and variable amounts of concordance between them.[8] Some aim to categorize attachment style while others rate degrees of attachment anxiety and avoidance.

Attachment Styles[edit]

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.[9][10] When shifts do occur it is usually with good reason, with 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) [11]


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. I don't worry about being alone or others not accepting me."[12]


Anxious-preoccupied people tend to view themselves less positively than okthey 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." [12]

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.[12]

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."[12] People with loss or trauma in childhood are at greater risk of developing this style of attachment.[13]

Insecure Attachment Styles in Healthcare Settings[edit]

Anxious-Preoccupied People with anxious-preoccupied attachment tend to be hypervigilant to signs of danger and to worry or catastrophize about symptoms. In health care appointments, their narrative is full of intense negative emotion but 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.[14][15]

Avoidant-Dismissive People with avoidant dismissive attachment emphasizetheir independence and minimizing expressing distress. They may delay seeking healthcare (see healthcare utilization), minimize reporting symptoms and disclose limited personal information.[14][15]

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.[14][15]

Working Model[edit]

Working models are representatives of the cognitive schema, or psychological structure (often unconscious), which underlie the different attachment classifications.[16] Working models develop in children over time based on their experiences with their attachment figures. The cognitive schema for attachment consists of views of the efficacy of self and other to create security in times of distress.

Bartholomew and Horowitz Model[edit]

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)[12]

  • 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 other

Prototype-Insecurity Classification Model[edit]

In 2012 Maunder and Hunter[17] 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[edit]

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.[1][18]

Physical health[edit]

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.[19] 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 glycosylated hemoglobin.[20] Larger scale evidence comes from a large American survey of self-reported attachment styles and physical illness conducted by McWilliams and Bailey.[21] 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, non-specific symptoms more often, and those with anxious-preoccupied classification had a higher rate of inflammation-based illnesses. This prospective study was particularly important because of the difficulty assigning causation in the often observed relationship between chronic pain and insecure attachment.[22][23] Further support is derived from experimental pain studies that have demonstrated numerous risk factors for the development of a chronic pain disorder associated with insecure adult attachment including lower perceived control of pain, higher pain catastrophizing and higher perceived pain intensity.[24]

Mental health[edit]

Attachment theory can be conceptualized as a theory of emotional regulation.[25][26] 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.[27] 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.[28][29] 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.[30]

Causal relationships between insecure attachment and mental illness may be complex.[7][8][15] 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.[8] 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.[31]

Mechanisms by which Attachment Influences Health[edit]

Maunder and Hunter outline 3 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 system.[1]

Attachment and Stress[edit]

See also: stress (biology), stress (psychological) The stress response in humans is largely governed by the hypothalamic-pituitary-adrenal axis (HPA) and sympathetic nervous system. The HPA axis has garnered particular attention from attachment researchers because it is known to be activated by social stressors.[32] The normal response for this system is to release stress hormones, particularly cortisol, for a brief duration and then shut itself off due to negative feedback, resulting in a short, strong release of cortisol. The HPA axis also follows a circadian rhythm, with highest release within about 30 minutes to 1 hour upon awakening, called the cortisol response to awakening (CRA), and a slow taper throughout the day. Researchers have looked at both cortisol response to stress (CRS) and CRA to determine if attachment anxiety and avoidance underlie individual differences in HPA activity.

Findings in the field have inconsistent. The evidence suggests that (a) individuals with high attachment anxiety perceive a higher degree of distress when faced with a stressor and have higher baseline anxiety compared to those low in attachment anxiety,[33][34][35][36] (b) most studies suggest higher cortisol reactivity to stress in anxiously attached individuals,[36][37][38][39][40][41] while two studies did not support this trend[33][42](c) avoidant-dismissive attachment has been less consistent, with some studies showing an increase in cortisol produced in response to a stressor,[37][43] and others not finding any differences in comparison to securely attached individuals[40][41](d) fearful attachment is associated with lower cortisol both upon awakening and in response to a stressor[35][40] although one study in pregnant women found less diurnal variation in those fearfully versus securely attached, leading to a higher bedtime cortisol level in the fearful group.[44] The finding that those with fearful attachment would show small cortisol reactivity in response to a stressor may seem counterintuitive but is in line with the predictions of stress researcher Bruce McEwen, who hypothesized that frequent early stressors in life would cause an initial hyper-reactivity in the HPA axis that would over time become pathologically sluggish as the individual ages, leading to greater overall cortisol release and less adaptive responsivity.[45]

Another related biological system that regulates stress response is the autonomic nervous system. In general, the sympathetic system is activated during times of stress and the parasympathetic system acts to decrease physical readiness for stress. These systems are sometimes called the “fight-or-flight” and “rest-or-digest” systems, respectively, and operate in a balance, as opposed to being totally on or off. Researchers can approximate the relative balance by looking at skin conductance, blood pressure and heart rate. Studies of this kind provided hard evidence that avoidant infants were truly distressed during the strange situation task[46] despite their minimally distressed appearance as they showed elevations in heart rate when caregivers were away and took longer to return to baseline when the caregiver returned in comparison to securely attached infants. Studies of skin conductance and heart rate in adults have shown that those with avoidant attachment and anxious attachment will show markers of increased distress during attachment and non-attachment stressors compared to those securely attached.[34][46]

Health behaviours[edit]

According to attachment theory people with insecure attachment have less effective strategies for dealing with negative emotions compared to people with secure attachment. One way in which insecurely 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.[15] Both attachment anxiety and attachment avoidance have been linked in separate studies to increasing the risk of eating disorders and substance use in adolescents.[47][48]

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.[49] These rates are similar to those found in other mental health populations.[50] 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.[49] The relationship between high attachment anxiety and disinhibited eating, or binge eating, has also been found in non-clinical[51][52] and pre-bariatric surgery populations.[53] 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[52] and another demonstrating a higher risk for metabolic syndrome at mid life.[54]

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.[55][56][57] A small study in Germany found that drug users were less likely to be secure than non-drug users and that heroine users in particular had a markedly high rate of fearful attachment.[58] 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. Jaak Panksepp hypothesized in the 1980s that endogenous opioids are responsible for the warm, affiliative, interpersonal feelings that come with social connection, and this has been supported by recent evidence showing that naloxone administration, an opioid blocker, results in a decreased feeling of social connection in healthy individuals.[59] Recent work also demonstrates that attachment dimensions have bearing on natural opioid signaling, with brain scans showing that those high in attachment avoidance have decreased opioid receptor availability.[60] In clinical samples insecure attachment is related to higher opioid use in chronic pain patients[61] and higher analgesic consumption during labor.[62] In a study of young adult females, drug use was one of several risky behaviours that occurred more frequently in those with insecure attachment along with unsafe driving and sexual practices.[63]

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.[64] 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.[65] 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.[65] 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.[66]

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[20][67][68] and more recently to no shows in scheduled follow up appointments.[69] Attachment avoidance has also been linked to lower rates of cervical cancer screening in both American and Iranian populations.[70][71]

Healthcare utilization[edit]

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.[14] 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.[72] High attachment anxiety has been associated with increased symptom reporting and visits to healthcare providers,[73] and high attachment avoidance associated with less visits and decreased treatment compliance[74][75][76]


  1. ^ a b c Hunter, JJ; Maunder, RG (2001). "Using attachment theory to understand illness behavior". General hospital psychiatry. 23 (4): 177–82. doi:10.1016/s0163-8343(01)00141-4. PMID 11543843. 
  2. ^ Kolb, LC (April 1982). "Attachment behavior and pain complaints". Psychosomatics. 23 (4): 413–25. doi:10.1016/s0033-3182(82)73404-8. PMID 7079441. 
  3. ^ Ravitz, P; Maunder, R; Hunter, J; Sthankiya, B; Lancee, W (October 2010). "Adult attachment measures: a 25-year review". Journal of psychosomatic research. 69 (4): 419–32. doi:10.1016/j.jpsychores.2009.08.006. PMID 20846544. 
  4. ^ a b Bretherton, Inge (1992). "The origins of attachment theory: John Bowlby and Mary Ainsworth". Developmental Psychology. 28 (5): 759–775. doi:10.1037/0012-1649.28.5.759. 
  5. ^ Mary, Ainsworth (1978). Patterns of attachment : a psychological study of the strange situation. Hillsdale, N.J.: Lawrence Erlbaum Associates. ISBN 978-0-89859-461-4. 
  6. ^ Main, M., & Solomon, J. (1986). Discovery of a new, insecure-disorganized/disoriented attachment pattern. In M. Yogman & T. B. Brazelton (Eds.), Affective development in infancy (pp. 95–124). Norwood, NJ: Ablex.
  7. ^ a b Fonagy, P (2001). Attachment and Psychoanalysis. Other Press. 
  8. ^ a b c Eagle, M. (2013). Attachment and Psychoanalysis: Theory, research and clinical. New York: Guilford. 
  9. ^ Weinfield, NS; Sroufe, LA; Egeland, B (2000). "Attachment from infancy to early adulthood in a high-risk sample: continuity, discontinuity, and their correlates". Child Development. 71 (3): 695–702. doi:10.1111/1467-8624.00178. PMID 10953936. 
  10. ^ Waters, E; Merrick, S; Treboux, D; Crowell, J; Albersheim, L (2000). "Attachment security in infancy and early adulthood: a twenty-year longitudinal study". Child Development. 71 (3): 684–9. doi:10.1111/1467-8624.00176. PMID 10953934. 
  11. ^ Segal, DL; Needham, TN; Coolidge, FL (2009). "Age differences in attachment orientations among younger and older adults: evidence from two self-report measures of attachment". International journal of aging & human development. 69 (2): 119–32. doi:10.2190/ag.69.2.c. PMID 19960862. 
  12. ^ a b c d e Bartholomew, K; Horowitz, LM (August 1991). "Attachment styles among young adults: a test of a four-category model". Journal of Personality and Social Psychology. 61 (2): 226–44. doi:10.1037/0022-3514.61.2.226. PMID 1920064. 
  13. ^ Byun, S; Brumariu, LE; Lyons-Ruth, K (2 February 2016). "Disorganized Attachment in Young Adulthood as Partial Mediator of Relations Between Severity of Childhood Abuse and Dissociation". Journal of Trauma & Dissociation. 17: 460–79. doi:10.1080/15299732.2016.1141149. PMID 26836233. 
  14. ^ a b c d Maunder, R; Hunter, J. Love, Fear and Health: How our attachments to others shape health and health care. Toronto: University of Toronto Press. 
  15. ^ a b c d e Hunter, J; Maunder, R (2015). Improving Patient Treatment with Attachment Theory: a guide for primary care providers and specialists. Springer. 
  16. ^ Zimmermann, P (December 1999). "Structure and functions of internal working models of attachment and their role for emotion regulation". Attachment & human development. 1 (3): 291–306. doi:10.1080/14616739900134161. PMID 11708228. 
  17. ^ Maunder, RG; Hunter, JJ (December 2012). "A prototype-based model of adult attachment for clinicians". Psychodynamic psychiatry. 40 (4): 549–73. doi:10.1521/pdps.2012.40.4.549. PMID 23216396. 
  18. ^ Feeney, J A (July 2000). "Implications of attachment style for patterns of health and illness". Child: Care, Health and Development. 26 (4): 277–288. doi:10.1046/j.1365-2214.2000.00146.x. 
  19. ^ Ozbay, F; Fitterling, H; Charney, D; Southwick, S (August 2008). "Social support and resilience to stress across the life span: a neurobiologic framework". Current psychiatry reports. 10 (4): 304–10. doi:10.1007/s11920-008-0049-7. PMID 18627668. 
  20. ^ a b Ciechanowski, P; Russo, J; Katon, W; Von Korff, M; Ludman, E; Lin, E; Simon, G; Bush, T (2004). "Influence of patient attachment style on self-care and outcomes in diabetes". Psychosomatic medicinevolume=66. 66 (5): 720–8. doi:10.1097/01.psy.0000138125.59122.23. PMID 15385697. 
  21. ^ McWilliams, Lachlan A.; Bailey, S. Jeffrey (2010-07-01). "Associations between adult attachment ratings and health conditions: evidence from the National Comorbidity Survey Replication". Health Psychology: Official Journal of the Division of Health Psychology, American Psychological Association. 29 (4): 446–453. doi:10.1037/a0020061. ISSN 1930-7810. PMID 20658833. 
  22. ^ Davies, K. A.; Macfarlane, G. J.; McBeth, J.; Morriss, R.; Dickens, C. (2009-06-01). "Insecure attachment style is associated with chronic widespread pain". Pain. 143 (3): 200–205. doi:10.1016/j.pain.2009.02.013. ISSN 1872-6623. PMC 2806947Freely accessible. PMID 19345016. 
  23. ^ Kowal, John; McWilliams, Lachlan A.; Péloquin, Katherine; Wilson, Keith G.; Henderson, Peter R.; Fergusson, Dean A. (2015-06-01). "Attachment insecurity predicts responses to an interdisciplinary chronic pain rehabilitation program". Journal of Behavioral Medicine. 38 (3): 518–526. doi:10.1007/s10865-015-9623-8. ISSN 1573-3521. PMID 25716120. 
  24. ^ Meredith, Pamela J.; Strong, Jenny; Feeney, Judith A. (2005-01-01). "Evidence of a relationship between adult attachment variables and appraisals of chronic pain". Pain Research & Management. 10 (4): 191–200. doi:10.1155/2005/745650. ISSN 1203-6765. PMID 16341306. 
  25. ^ Waters, Sara F.; Virmani, Elita A.; Thompson, Ross A.; Meyer, Sara; Raikes, H. Abigail; Jochem, Rachel (2009-09-23). "Emotion Regulation and Attachment: Unpacking Two Constructs and Their Association". Journal of Psychopathology and Behavioral Assessment. 32 (1): 37–47. doi:10.1007/s10862-009-9163-z. ISSN 0882-2689. PMC 2821505Freely accessible. PMID 20174446. 
  26. ^ Mikulincer, Mario; Shaver, Phillip R.; Pereg, Dana. "Attachment Theory and Affect Regulation: The Dynamics, Development, and Cognitive Consequences of Attachment-Related Strategies". Motivation and Emotion. 27 (2): 77–102. doi:10.1023/A:1024515519160. ISSN 0146-7239. 
  27. ^ Sroufe, L. A.; Carlson, E. A.; Levy, A. K.; Egeland, B. (1999-01-01). "Implications of attachment theory for developmental psychopathology". Development and Psychopathology. 11 (1): 1–13. doi:10.1017/s0954579499001923. ISSN 0954-5794. PMID 10208353. 
  28. ^ Fearon, R. Pasco; Bakermans-Kranenburg, Marian J.; van IJzendoorn, Marinus H.; Lapsley, Anne-Marie; Roisman, Glenn I. (March 2010). "The Significance of Insecure Attachment and Disorganization in the Development of Children's Externalizing Behavior: A Meta-Analytic Study". Child Development. 81 (2): 435–456. doi:10.1111/j.1467-8624.2009.01405.x. 
  29. ^ Groh, Ashley M.; Roisman, Glenn I.; van IJzendoorn, Marinus H.; Bakermans-Kranenburg, Marian J.; Fearon, R. Pasco (January 2012). "The Significance of Insecure and Disorganized Attachment for Children's Internalizing Symptoms: A Meta-Analytic Study". Child Development. 83: 591–610. doi:10.1111/j.1467-8624.2011.01711.x. PMID 22235928. 
  30. ^ Cassidy, J.; Shaver, P.R. (2008). Handbook of attachment: Theory, research, and clinical applications. Guilford. pp. 718–744. 
  31. ^ Mikulincer, M; Shaver, PR (February 2012). "An attachment perspective on psychopathology". World psychiatry : official journal of the World Psychiatric Association (WPA). 11 (1): 11–5. doi:10.1016/j.wpsyc.2012.01.003. PMC 3266769Freely accessible. PMID 22294997. 
  32. ^ Diamond, Lisa M. (November 2001). "Contributions of Psychophysiology to Research on Adult Attachment: Review and Recommendations". Personality and Social Psychology Review. 5 (4): 276–295. doi:10.1207/S15327957PSPR0504_1. 
  33. ^ a b Ditzen, B; Schmidt, S; Strauss, B; Nater, UM; Ehlert, U; Heinrichs, M (May 2008). "Adult attachment and social support interact to reduce psychological but not cortisol responses to stress". Journal of psychosomatic research. 64 (5): 479–86. doi:10.1016/j.jpsychores.2007.11.011. PMID 18440400. 
  34. ^ a b Maunder, Robert G.; Lancee, William J.; Nolan, Robert P.; Hunter, Jonathan J.; Tannenbaum, David W. (March 2006). "The relationship of attachment insecurity to subjective stress and autonomic function during standardized acute stress in healthy adults". Journal of Psychosomatic Research. 60 (3): 283–290. doi:10.1016/j.jpsychores.2005.08.013. 
  35. ^ a b Kidd, Tara; Hamer, Mark; Steptoe, Andrew (September 2013). "Adult attachment style and cortisol responses across the day in older adults". Psychophysiology. 50 (9): 841–847. doi:10.1111/psyp.12075. PMC 4298031Freely accessible. 
  36. ^ a b Dewitte, Marieke; De Houwer, Jan; Goubert, Liesbet; Buysse, Ann (September 2010). "A multi-modal approach to the study of attachment-related distress". Biological Psychology. 85 (1): 149–162. doi:10.1016/j.biopsycho.2010.06.006. 
  37. ^ a b Powers, SI; Pietromonaco, PR; Gunlicks, M; Sayer, A (April 2006). "Dating couples' attachment styles and patterns of cortisol reactivity and recovery in response to a relationship conflict". Journal of Personality and Social Psychology. 90 (4): 613–28. doi:10.1037/0022-3514.90.4.613. PMID 16649858. 
  38. ^ Quirin, M; Pruessner, JC; Kuhl, J (June 2008). "HPA system regulation and adult attachment anxiety: individual differences in reactive and awakening cortisol". Psychoneuroendocrinology. 33 (5): 581–90. doi:10.1016/j.psyneuen.2008.01.013. PMID 18329180. 
  39. ^ Laurent, Heidemarie; Powers, Sally (September 2007). "Emotion regulation in emerging adult couples: Temperament, attachment, and HPA response to conflict". Biological Psychology. 76 (1–2): 61–71. doi:10.1016/j.biopsycho.2007.06.002. PMC 2041804Freely accessible. 
  40. ^ a b c Kidd, Tara; Hamer, Mark; Steptoe, Andrew (July 2011). "Examining the association between adult attachment style and cortisol responses to acute stress". Psychoneuroendocrinology. 36 (6): 771–779. doi:10.1016/j.psyneuen.2010.10.014. PMC 3114075Freely accessible. PMID 21106296. 
  41. ^ a b Smyth, Nina; Thorn, Lisa; Oskis, Andrea; Hucklebridge, Frank; Evans, Phil; Clow, Angela (11 March 2015). "Anxious attachment style predicts an enhanced cortisol response to group psychosocial stress". Stress. 18 (2): 143–148. doi:10.3109/10253890.2015.1021676. 
  42. ^ Smeets, T (May 2010). "Autonomic and hypothalamic-pituitary-adrenal stress resilience: Impact of cardiac vagal tone". Biological Psychology. 84 (2): 290–5. doi:10.1016/j.biopsycho.2010.02.015. PMID 20206227. 
  43. ^ Rifkin-Graboi, A (May 2008). "Attachment status and salivary cortisol in a normal day and during simulated interpersonal stress in young men". Stress (Amsterdam, Netherlands). 11 (3): 210–24. doi:10.1080/10253890701706670. PMID 18465468. 
  44. ^ Costa-Martins, José Manuel; Moura-Ramos, Mariana; Cascais, Maria João; da Silva, Carlos Fernandes; Costa-Martins, Henriqueta; Pereira, Marco; Coelho, Rui; Tavares, Jorge (11 January 2016). "Adult attachment style and cortisol responses in women in late pregnancy". BMC Psychology. 4 (1). doi:10.1186/s40359-016-0105-8. 
  45. ^ McEwen, BS (February 2000). "Allostasis and allostatic load: implications for neuropsychopharmacology". Neuropsychopharmacology. 22 (2): 108–24. doi:10.1016/s0893-133x(99)00129-3. PMID 10649824. 
  46. ^ a b Gander, Manuela; Buchheim, Anna (19 February 2015). "Attachment classification, psychophysiology and frontal EEG asymmetry across the lifespan: a review". Frontiers in Human Neuroscience. 9. doi:10.3389/fnhum.2015.00079. 
  47. ^ O'Kearney, R (September 1996). "Attachment disruption in anorexia nervosa and bulimia nervosa: a review of theory and empirical research". The International Journal of Eating Disorders. 20 (2): 115–27. doi:10.1002/(sici)1098-108x(199609)20:2<115::aid-eat1>;2-j. PMID 8863063. 
  48. ^ Schindler, Andreas; Bröning, Sonja (25 November 2014). "A Review on Attachment and Adolescent Substance Abuse: Empirical Evidence and Implications for Prevention and Treatment". Substance Abuse. 36 (3): 304–313. doi:10.1080/08897077.2014.983586. 
  49. ^ a b Zachrisson, HD; Skårderud, F (March 2010). "Feelings of insecurity: review of attachment and eating disorders". European Eating Disorders Review. 18 (2): 97–106. doi:10.1002/erv.999. PMID 20148392. 
  50. ^ Bakermans-Kranenburg, Marian J.; van IJzendoorn, Marinus H. (May 2009). "The first 10,000 Adult Attachment Interviews: distributions of adult attachment representations in clinical and non-clinical groups". Attachment & Human Development. 11 (3): 223–263. doi:10.1080/14616730902814762. 
  51. ^ Han, Suejung; Pistole, M. Carole (2014). "College Student Binge Eating: Insecure Attachment and Emotion Regulation". Journal of College Student Development. 55 (1): 16–29. doi:10.1353/csd.2014.0004. 
  52. ^ a b Wilkinson, L L; Rowe, A C; Bishop, R J; Brunstrom, J M (30 March 2010). "Attachment anxiety, disinhibited eating, and body mass index in adulthood". International Journal of Obesity. 34 (9): 1442–1445. doi:10.1038/ijo.2010.72. 
  53. ^ Shakory, Sharry; Van Exan, Jessica; Mills, Jennifer S.; Sockalingam, Sanjeev; Keating, Leah; Taube-Schiff, Marlene (August 2015). "Binge eating in bariatric surgery candidates: The role of insecure attachment and emotion regulation". Appetite. 91: 69–75. doi:10.1016/j.appet.2015.03.026. 
  54. ^ Davis, Cynthia R.; Usher, Nicole; Dearing, Eric; Barkai, Ayelet R.; Crowell-Doom, Cynthia; Neupert, Shevaun D.; Mantzoros, Christos S.; Crowell, Judith A. (October 2014). "Attachment and the Metabolic Syndrome in Midlife". Psychosomatic Medicine. 76 (8): 611–621. doi:10.1097/PSY.0000000000000107. 
  55. ^ Kassel, JD; Wardle, M; Roberts, JE (June 2007). "Adult attachment security and college student substance use". Addictive behaviors. 32 (6): 1164–76. doi:10.1016/j.addbeh.2006.08.005. PMID 16996225. 
  56. ^ Olsson, Craig A.; Moyzis, Robert K.; Williamson, Elizabeth; Ellis, Justine A.; Parkinson-Bates, Mandy; Patton, George C.; Dwyer, Terry; Romaniuk, Helena; Moore, Elya E. (2013). "Gene-environment interaction in problematic substance use: interaction between and insecure attachments". Addiction Biology. 18 (4): 717–726. doi:10.1111/j.1369-1600.2011.00413.x. 
  57. ^ Zeinali, A; Sharifi, H; Enayati, M; Asgari, P; Pasha, G (2011). "The mediational pathway among parenting styles, attachment styles and self-regulation with addiction susceptibility of adolescents". Journal of research in medical sciences : the official journal of Isfahan University of Medical Sciences. 16 (9): 1105–21. PMC 3430035Freely accessible. PMID 22973379. 
  58. ^ Schindler, Andreas; Thomasius, Rainer; Petersen, Kay; Sack, Peter-Michael (2009). "Heroin as an attachment substitute? Differences in attachment representations between opioid, ecstasy and cannabis abusers". Attachment & Human Development. 11 (3): 307–330. doi:10.1080/14616730902815009. 
  59. ^ Inagaki, Tristen K.; Ray, Lara A.; Irwin, Michael R.; Way, Baldwin M.; Eisenberger, Naomi I. (2016). "Opioids and social bonding: naltrexone reduces feelings of social connection". Social Cognitive and Affective Neuroscience. 11: 728–735. doi:10.1093/scan/nsw006. 
  60. ^ Nummenmaa, Lauri; Manninen, Sandra; Tuominen, Lauri; Hirvonen, Jussi; Kalliokoski, Kari K.; Nuutila, Pirjo; Jääskeläinen, Iiro P.; Hari, Riitta; Dunbar, Robin I.M.; Sams, Mikko (2015). "Adult attachment style is associated with cerebral μ-opioid receptor availability in humans". Human Brain Mapping. 36 (9): 3621–3628. doi:10.1002/hbm.22866. 
  61. ^ Andersen, TE (May 2012). "Does attachment insecurity affect the outcomes of a multidisciplinary pain management program? The association between attachment insecurity, pain, disability, distress, and the use of opioids". Social Science & Medicine. 74 (9): 1461–8. doi:10.1016/j.socscimed.2012.01.009. PMID 22398142. 
  62. ^ Costa-Martins, JM; Pereira, M; Martins, H; Moura-Ramos, M; Coelho, R; Tavares, J (April 2014). "The role of maternal attachment in the experience of labor pain: a prospective study". Psychosomatic Medicine. 76 (3): 221–8. doi:10.1097/psy.0000000000000040. PMID 24608037. 
  63. ^ Ahrens, KR; Ciechanowski, P; Katon, W (2012). "Associations between adult attachment style and health risk behaviors in an adult female primary care population". Journal of psychosomatic research. 72 (5): 364–70. doi:10.1016/j.jpsychores.2012.02.002. PMC 3816981Freely accessible. PMID 22469278. 
  64. ^ Simons, Leslie Gordon; Sutton, Tara E.; Simons, Ronald L.; Gibbons, Frederick X.; Murry, Velma McBride (2015). "Mechanisms That Link Parenting Practices to Adolescents' Risky Sexual Behavior: A Test of Six Competing Theories". Journal of Youth and Adolescence. 45 (2): 255–270. doi:10.1007/s10964-015-0409-7. PMID 26718543. 
  65. ^ a b Davis, Deborah; Shaver, Phillip R.; Vernon, Michael L. (1 August 2004). "Attachment Style and Subjective Motivations for Sex". Personality and Social Psychology Bulletin. 30 (8): 1076–1090. doi:10.1177/0146167204264794. 
  66. ^ Beaulieu-Pelletier, Genevieve; Philippe, Frederick L.; Lecours, Serge; Couture, Stéphanie (2011). "The role of attachment avoidance in extradyadic sex". Attachment & Human Development. 13 (3): 293–313. doi:10.1080/14616734.2011.562419. 
  67. ^ Calia, Rosaria; Lai, Carlo; Aceto, Paola; Luciani, Massimiliano; Camardese, Giovanni; Lai, Silvia; Amato, Giara; Pietroni, Valentina; Salerno, Maria Paola; Pedroso, Jose Alberto; Romagnoli, Jacopo; Citterio, Franco (2015). "Attachment style predict compliance, quality of life and renal function in adult patients after kidney transplant: preliminary results". Renal Failure. 37 (4): 678–680. doi:10.3109/0886022X.2015.1010989. 
  68. ^ Bennett, JK; Fuertes, JN; Keitel, M; Phillips, R (2011). "The role of patient attachment and working alliance on patient adherence, satisfaction, and health-related quality of life in lupus treatment". Patient education and counseling. 85 (1): 53–9. doi:10.1016/j.pec.2010.08.005. PMID 20869188. 
  69. ^ Sockalingam, Sanjeev; Cassin, Stephanie; Hawa, Raed; Khan, Attia; Wnuk, Susan; Jackson, Timothy; Okrainec, Allan (2013). "Predictors of Post-bariatric Surgery Appointment Attendance: the Role of Relationship Style". Obesity Surgery. 23 (12): 2026–2032. doi:10.1007/s11695-013-1009-9. 
  70. ^ Hill, EM; Gick, ML (2013). "Attachment and barriers to cervical screening". Journal of health psychology. 18 (5): 648–57. doi:10.1177/1359105312454910. PMID 22933580. 
  71. ^ Hajializadeh, K; Ahadi, H; Jomehri, F; Rahgozar, M (2013). "Psychosocial predictors of barriers to cervical cancer screening among Iranian women: the role of attachment style and social demographic factors". Journal of preventive medicine and hygiene. 54 (4): 218–22. PMC 4718322Freely accessible. PMID 24779284. 
  72. ^ Feeney, JA; Ryan, SM (July 1994). "Attachment style and affect regulation: relationships with health behavior and family experiences of illness in a student sample". Health psychology : official journal of the Division of Health Psychology, American Psychological Association. 13 (4): 334–45. doi:10.1037/0278-6133.13.4.334. PMID 7957012. 
  73. ^ Ciechanowski, PS; Katon, WJ; Russo, JE; Walker, EA (January 2001). "The patient-provider relationship: attachment theory and adherence to treatment in diabetes". The American Journal of Psychiatry. 158 (1): 29–35. doi:10.1176/appi.ajp.158.1.29. PMID 11136630. 
  74. ^ Taylor, RE; Marshall, T; Mann, A; Goldberg, DP (2012). "Insecure attachment and frequent attendance in primary care: a longitudinal cohort study of medically unexplained symptom presentations in ten UK general practices". Psychological Medicine. 42 (4): 855–64. doi:10.1017/s0033291711001589. PMID 21880165. 
  75. ^ Sullivan, M. D.; Ciechanowski, P. S.; Russo, J. E.; Soine, L. A.; Jordan-Keith, K.; Ting, H. H.; Caldwell, J. H. (2009). "Understanding Why Patients Delay Seeking Care for Acute Coronary Syndromes". Circulation: Cardiovascular Quality and Outcomes. 2 (3): 148–154. doi:10.1161/circoutcomes.108.825471. 
  76. ^ Brenk-Franz, Katja; Strauss, Bernhard; Tiesler, Fabian; Fleischhauer, Christian; Ciechanowski, Paul; Schneider, Nico; Gensichen, Jochen (2015). "The Influence of Adult Attachment on Patient Self-Management in Primary Care - The Need for a Personalized Approach and Patient-Centred Care". PLOS ONE. 10 (9): e0136723. doi:10.1371/journal.pone.0136723. PMC 4575213Freely accessible. PMID 26381140.