Jonathan J. Hunter

Attachment and Psychosomatic Medicine: Developmental Contributions to Stress and Disease

Objective The object of this study was to evaluate the evidence linking attachment insecurity to illness. Attachment theory describes lifelong patterns of response to threat that are learned in the interaction between an infant and his or her primary caregiver. Despite its biopsychosocial domain, attachment theory has only recently been applied to psychosomatic medicine. Method MEDLINE and PsychInfo databases were searched from 1966 to 2000 for English language papers with key words “attachment” and “object relations.” Papers and their cited references were reviewed if they were directly related to physical illness, symptoms, or physiology. A hypothetical causal model was developed. Results Direct and indirect evidence from survey studies supports an association between attachment insecurity and disease. Animal studies and human experiments suggest that attachment contributes to individual differences in physiological stress response. There is also less robust support for insecure attachment leading to symptom reporting and to more frequent health risk behaviors, especially substance use and treatment nonadherence. Evidence supports the prediction from attachment theory that the benefits of social support derive more from attachment relationships than nonattachment relationships. Conclusions Although the available data are suggestive rather than conclusive, the data can be organized into a model that describe attachment insecurity leading to disease risk through three mechanisms. These are increased susceptibility to stress, increased use of external regulators of affect, and altered help-seeking behavior. This model warrants further prospective investigation.

Using attachment theory to understand illness behavior.

This article examines a model of illness as a stressor that activates an individuals characteristic attachment behaviors. These behaviors are the result of the attachment system, a mammalian trait that exists in order to maximize the odds of survival of an infant born without the necessary maturation for immediate independence. Attachment concepts, such as attachment style, coherence, and reflective functioning, are briefly explained, followed by examples of their application to the psychological management of patients with medical or surgical illness. Attachment theory provides a unique, simple, and pragmatically useful model for understanding the particular ways that individuals can feel and react when stressed by illness, and how the professional may help manage that distress.

Attachment Relationships as Determinants of Physical Health

Childhood adversity alters the relational world of the child and inhibits the development of secure attachment bonds. The purpose of this article is to survey recent evidence that attachment insecurity has the potential to impair physical health throughout the lifespan. It is proposed that attachment insecurity contributes to disease risk through a range of mechanisms which include (1) disturbances in arousal and recovery within physiological systems that respond to stress; (2) physiological links between the mediators of social relationships, stress, and immunity; (3) links between relationship style and various health behaviors; and (4) disease risk factors that serve as external regulators of dysphoric affect, such as nicotine and alcohol. The evidence for these mechanisms, particularly the evidence that has accumulated since the model was first proposed in 2000, is presented and discussed.

Assessing patterns of adult attachment in medical patients

OBJECTIVE Patterns of adult attachment affect physical health and yet are unfamiliar to many clinicians. The purpose of this review was to derive descriptions of prototypic patterns of adult attachment that are relevant to health care. METHODS Observations from attachment research using diverse methods to measure adult attachment were reviewed. A synthetic approach was used to integrate these observations into coherent descriptions of prototypic patterns of attachment. RESULTS Four patterns of adult attachment (secure, preoccupied, dismissing and fearful) are distinguished by prototypic patterns in intimate relationships, affect regulation, use of social support, trait descriptors, mentalization and narrative coherence. These patterns are linked to health care relationships and health outcomes. CONCLUSION Prototypic descriptions of patterns of adult attachment may guide clinicians in appreciating individual differences in interpersonal style that affect the health of patients.

Long-term psychological and occupational effects of providing hospital healthcare during SARS outbreak.

TOC Summary Line: Healthcare workers in hospitals affected by SARS experience increased psychological stress 1–2 years after the outbreak.

The BRCA Self-Concept Scale: a new instrument to measure self-concept in BRCA1/2 mutation carriers.

Genetic testing for BRCA1/2 has psychosocial impacts including those related to views of personal health, sense of self and identity and body image. The centrality of a persons self‐concept in maintaining physical and psychosocial well‐being has been well recognized; however, to date research exploring altered self‐concept related to carrier knowledge is limited.

A supportive-expressive group intervention for women with a family history of breast cancer: results of a phase II study.

Background: Evidence suggests that there are significant psychological and behavioural sequelae associated with having a family history of breast cancer (BC) which can interfere with comprehension of risk estimates.

Attachment Insecurity Moderates the Relationship Between Disease Activity and Depressive Symptoms in Ulcerative Colitis

Background: Among people with ulcerative colitis, depression occurs more frequently when inflammation is active. We hypothesized that individual differences in interpersonal style affect the risk that active disease will be accompanied by depressive symptoms. Methods: In this study, disease activity, depressive symptoms, and 2 dimensions of interpersonal style, attachment anxiety and attachment avoidance, were measured in 146 ulcerative colitis outpatients at time 1 and in 99 of these patients at a second time‐point, 7 to 37 months later. Test‐retest correlations of attachment anxiety (r = 0.83, P < 0.001) and attachment avoidance (r = 0.76, P < 0.001) confirmed that these dimensions are stable. Results: There was a stepwise increase in the correlation between time 2 disease activity and depression from the lowest tercile of attachment anxiety (r = 0.00, P = 0.99), through the middle tercile (r = 0.36, P = 0.05), to the highest tercile (r = 0.52, P = 0.002). For attachment avoidance, disease activity and depression were only significantly correlated in the highest tercile (r = 0.49, P = 0.005). Conclusions: Attachment anxiety meets all tested criteria as a moderator of the relationship between disease activity and depressive symptoms. Further attention to interpersonal style as a moderator of depressive risk in ulcerative colitis is warranted.

Factors associated with the psychological impact of severe acute respiratory syndrome on nurses and other hospital workers in Toronto.

Objectives: A survey was conducted to measure psychological stress in hospital workers and measure factors that may have mediated acute traumatic responses. Methods: A self-report survey was completed by 1557 healthcare workers at three Toronto hospitals in May and June 2003. Psychological stress was measured with the Impact of Event Scale. Scales representing attitudes to the outbreak were derived by factor analysis of 76 items probing attitudes to severe acute respiratory syndrome. The association of Impact of Event Scale scores to job role and contact with severe acute respiratory syndrome patients was tested by analysis of variance. Between-group differences in attitudinal scales were tested by multivariate analysis of variance. Attitudinal scales were tested as factors mediating the association of severe acute respiratory syndrome patient contact and job role with total Impact of Event Scale by linear regression. Results: Higher Impact of Event Scale scores are found in nurses and healthcare workers having contact with patients with severe acute respiratory syndrome. The relationship of these groups to the Impact of Event Scale score is mediated by three factors: health fear, social isolation, and job stress. Conclusions: Although distress in response to the severe acute respiratory syndrome outbreak is greater in nurses and those who care for patients with severe acute respiratory syndrome, these relationships are explained by mediating variables that may be available for interventions to reduce stress in future outbreaks. In particular, the data suggest that the targets of intervention should include job stress, social isolation, and health fear. SARS = severe acute respiratory syndrome; IES = Impact of Event Scale; HCW = healthcare worker; MSH = Mount Sinai Hospital; SMH = St. Michael’s Hospital; CAMH = Centre for Addiction and Mental Health.

Psychobiological subtypes of ulcerative colitis: pANCA status moderates the relationship between disease activity and psychological distress.

INTRODUCTION:Studies of psychological factors in ulcerative colitis (UC) have produced inconsistent findings. This study sought to determine whether perinuclear antineutrophil cytoplasmic antibody (pANCA) demarcates subtypes which differ with respect to psychobiological interactions.METHODS:In 148 outpatients with UC, the strength of the relationship between current UC disease activity and psychological distress was assessed. pANCA was determined by ELISA and immunofluorescence, disease activity was determined by symptoms, physical examination, and endoscopy using the St. Marks index, and depressive symptoms and health anxiety were measured with self-report scales. Pearson correlations between disease activity and depressive symptoms and between disease activity and health anxiety were calculated.RESULTS:In 74 pANCA negative subjects, the relationship between disease activity and measures of psychological distress was significant for disease activity-depression (partial correlation = 0.48, p < 0.001) and for disease activity-health anxiety (partial correlation = 0.64, p < 0.001), whereas in 74 pANCA positive subjects, no relationships were found (disease activity-depression: partial correlation = 0.18, p = 0.14; disease activity-health anxiety: partial correlation = 0.20, p = 0.09). The differences in the strength of correlation between pANCA positive and pANCA negative subjects were statistically significant for both disease activity-depression (z = 2.0, p = 0.02) and activity-health anxiety (z = 3.3, p < 0.001).CONCLUSIONS:pANCA status demarcates psychobiologically distinct subtypes of UC, such that the absence of pANCA is associated with greater psychobiological interaction. These findings have implications for clinical care and understanding the pathophysiology of intestinal inflammation.