How does insecure attachment contribute to health outcomes in adults?

A Systematic review examining the discourse of insecure attachment and the

body/mind connection

Abstract

BACKGROUND
Research suggests that there is a disparity in health outcomes between securely and
insecurely attached individuals due to individual differences in psychophysiological
responses and emotional regulation following actual or perceived stressors.

OBJECTIVES
This Review examines how the attachment process exerts an influence over health
outcomes in adults and whether a connection exists between insecure attachment
and ill-health. In order to illustrate the impact of the attachment system on mediators
of physical health, consideration is given to emotions and stress-response, along
with a discussion of the autonomic nervous system and neuro-endocrine system.

METHODS
A search of electronic databases CINAHL, MEDLINE, PsycINFO, PsycARTICLES,
Scopus, Psychology and behavioural sciences collection and EMBASE identified
studies exploring insecure attachment and physical illness, physiological ill-health or
evidence of increased risk for physical ill-health. Studies addressing psychological
conditions, autism, health seeking behaviour; health-related coping; social bonding,
attachment and therapy or illness perception were not included.

RESULTS
Best Evidence Synthesis of the results of five studies included in the Review
revealed an association between insecure attachment and physical illness or
increased risk for ill-health, with an emphasis on immune and inflammatory
conditions.

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CONCLUSION
It can be concluded that insecure attachment may be a predicator of ill-health in
adults, but that individual differences in secure attachment relationships over time
may alter health outcomes. Higher physiological and more prolonged stress
responses of insecurely attached individuals, especially those with avoidant
attachment, may exacerbate vulnerability to ill-health outcomes in adults.

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Contents

Title Page i
Abstract ii
Acknowledgements iii
Contents iv
List of contents v
List of Tables vii
List of Figures and Boxes viii

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List of contents

1.0 Introduction 1

2.0 Background and Literature Review 1

2.1 Human Attachment process . 1
2.2 Attachment styles ... 2
2.3 Attachment from infant to adult 4
2.4 Emotion regulation 6
2.5 Stress response . 7
2.6 Emotions & stress .. 9
2.7 Current attachment theories in neuroscience .. 10
2.8 Attachment, the Autonomic Nervous System (ANS)
& HPA axis .. 11
2.9 Disease, illness and attachment style 12
2.10 Rationale for this Review .. 14

3.0 Aims and Objectives 16

3.1 Aims 16
3.2 Objectives . 16

4.0 Methods .. 17
4.1 Study Methodology . 17
4.2 Review Criteria 18
4.3 Inclusion and Exclusion Criteria . 20
4.4 Search Strategy .. 22
4.5 Selection of Studies 24
4.5.1 First Stage Selection .. 25
4.5.2 Second Stage Selection 25
4.6 Assessment of Quality 26
4.6.1 Quality Checklists 28
4.6.2 Discussion of the quality of studies . 30
4.6.3 Discussion of Adult Attachment tools ... 31

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 4.7 Data Extraction 32
4.8 Data Analysis Methods .. 34

5.0 Results 36
5.1 First stage selection of studies .. 37
5.2 Second stage selection of studies 39
5.2.1 Studies excluded at Stage Two . 40
5.3 Quality Assessment . 41
5.3.1 Studies excluded at Quality Assessment stage .. 47
5.3.2 Discussion of quality of included studies 48
5.4 Description of studies included in the Review 50
5.5 Data Extraction . 51
5.5 Summary of Extracted Data 53
5.5 Attachment measurement tools . 54
5.6 Discussion of outcome statistics for individual
Studies .. 56
5.6.1 Study 1 Picardi et al (2012) 56
5.6.2 Study 2 Puig et al (2013) 56
5.6.3 Study 3 - Scheidt et al (2000) 57
5.6.4 Study 4 Agnostini et al (2010) 58
5.6.5 Study 5 Ercolani et al (2004) .. 58
5.7 Narrative synthesis of results 59

6.0 Discussion .. 60

7.0 Limitations .. 63

8.0 Conclusion . 64

9.0 Recommendations for future research . 64

References 66

Appendices ... 83

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List of Tables
Table 4.1: PICOT and selection criteria .. 24
Table 4.2: Example Quality Checklist .. 28
Table 4.3: Example of Data Extraction form 33
Table 5.1: Summary of results of preliminary search
using keywords 37
Table 5.2: First selection stage 38
Table 5.3: Study Selection Form .. 40
Table 5.4: Definition of acceptable quality . 42
Table 5.5: Quality Assessment for Case Control Studies 42
Table 5.6: Quality Assessment for Cross-Sectional Studies 43
Table 5.7: Quality Assessment for Cohort Studies 44
Table 5.8: Synthesis of Quality Assessment results . 46
Table 5.9: Synthesis of Data Extraction forms 51
Table 5.10: Attachment Measurement tools and terms
for attachment status 55

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List of Figures and Boxes

Fig 2.1: Model of individual differences in adult attachment 3

Fig. 2.2: Insecure attachment, affect regulation and cognition 8
Fig 2.3: Stress response and individual differences . 10
Fig 2.4: Stress response reactivity 13
Fig 4.1: Combining Keywords with Boolean operators 23
Fig 4.2: Data Synthesis Process 36
Fig 5.1: PRISMA Flow Chart ... 46
Fig 5.2: Insecure attachment and associations with
health outcomes . 60
Box 4.1: PICOT Format 19
Box 5.1: Studies identified for inclusion in Stage Two 39

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1.0 Introduction
Over the past 20 years, interest has grown in the field of physical health
implications regarding attachment, early social interactions and
development (Gallo & Matthews, 2006). The quality of attachments with
primary caregivers in early childhood form the foundation for attachment
style and individual differences in the regulation of affect (non-conscious
experience of intensity of emotions) and responses to stress (Picardi et al,
2012; Tacon, 2002). The attachment system responds to an individuals
perception of security and support within caregiving and interpersonal
relationships. If these support systems are inadequate, an insecure
attachment style is formed, where defensive emotion regulation strategies
are employed to regulate stress in the actual or perceived absence of
support from others. These strategies shape individual differences in
psychophysiological stress responses and impact on the ability of the
body to maintain homeostasis or balance (Everly & Lating, 2002).
Dysfunctional chronic stress reactivity patterns have been linked to
vulnerability for increased physical ill-health outcomes in adults
(Pietromonaco & Powers, 2015). The concepts of the development of disease
and physiology have also advanced within the past 20 years, for example,
cardiovascular disease was once imagined to be solely due to simple
build-up of plaque but is now seen as a combination of predisposing
factors such as tissue injury related to immune function, nervous system
and endocrine activation (Baum et al, 2012). This Review examines the
pathway of insecure attachment, resulting psychophysiological functioning
and possible contributions to ill-health outcomes in adults.

2.0 Background and Literature Review

2.1 H UMAN ATTACHMENT PROCESS

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To protect against threats and to alleviate distress, the human psycho-biological
system prompts the seeking of closeness with attachment figures (Bowlby, 1988).
In Bowlbys Attachment Theory, it is posited that different types of attachment are
observable in early childhood. The attachment system responds in relation to
interaction, support and responsiveness from the attachment figure, which leads to
attachment security. Insecure attachment occurs when a direct, security seeking
strategy is not satisfied, i.e. when there is no reliable support or there is a failure to
provide adequate relief from distress. The insecurely attached child forms negative
models of themselves and others leading to a defensive secondary attachment
strategy, of either hyper or deactivation of the attachment system (Brennan et al,
1998; Shaver et al, 1987). Hyper-activating strategies, associated with anxious
attachment, lead to over-vigilance for potential threats and seeking excessive
reassurance. Deactivating strategies, seen in avoidance attachment, involve
minimising or supressing distress and behaviour of distancing from others.
(Pietromonaco & Powers, 2015). Secondary attachment strategies are defensive
methods of relating to others which disrupt normal proximity seeking, resulting in
difficulties in sending and receiving social messages (Mikulincer & Shaver, 2007).
Hofer (2006) believes that the study of developmental processes, such as
attachment, provides important clues about the origins of a wide spectrum of clinical
conditions.

Secure individuals learn that their personal efforts are usually effective in reducing
stress and dealing with obstacles and can be supplemented by seeking help from
others for problem solving. A prerequisite of problem solving is recognising that ones
initial attempt is not effective; securely attached people who have experience of
supportive attachment figures can review their original beliefs without excessive fear
of humiliation, rejection and criticism which allows them to tolerate uncertainty and
explore more freely (Gross, 2013). They tend not to deny negative emotions but are
able to provisionally tolerate them to enable them to solve frustrating situations
(Cassidy, 1994). This leads to the ability to notice, feel and think about emotional or
mental states in a self-reflexive way in order to understand and make sense of their
experiences (Fonagy et al, 1991).

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2.2 ATTACHMENT STYLES

Attachment styles or internal working models are conscious and unconscious

processes which guide perceptions and prompt distinctive emotions and defence
Mechanisms. An attachment style will encompass rules for regulating emotions and
for processing, or failing to process, attachment-related information (Silva et al,
2012).

FIG 2.1: M ODEL OF INDIVIDUAL DIFFERENCES IN ADULT ATTACHMENT

Secure attachment is correlated

with evaluation and emotion
regulation (Gross, 2013), and
involves a constructive approach
to relationships and engenders
lower stress reactivity (Grimm et
al, 2014). Anxious and avoidant
attachment are dysfunctional

(Fraley, 2010) adaptive

responses (with individual
differences shown in Fig 2.1) which Ainsworth (1991) attributes to
particular types of caregiving. An insecure attachment style does not
prevent relationship or attachment formation
But has an impact on strategies for stress alleviation and the regulation or
effectiveness of these strategies (Carpenter & Kirkpatrick, 1996).

Threat appraisals, as viewed by individuals with insecure attachment styles,

frequently increase access to negative thoughts and memories (separation or
rejection from attachment figures) which cause the access to these concerns to
increase every time proximity seeking tendencies are activated (Mikulincer & Shaver,
2003). This leads to the belief that proximity seeking may fail, which compels
insecure people to treat unresolved distress via hyper-activating or deactivating
attachment strategies (Gross, 2013).

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Avoidant attachment is associated with deactivating strategies to suppress and
downplay emotions (Gross, 2003) while maintaining high levels of physiological
stress response. (Dozier & Kobak, 1992). This secondary defence strategy is learnt
through failed or frustrated attempts for closeness and support, where
acknowledgement of distress has led to rejection (Cassidy & Kobak, 1988). When
threats (personal or relational) are encountered the attachment system is activated
to block associated concerns, feelings, memories and tendencies for action from the
consciousness i.e. to avoid of noticing and experiencing personal negative emotional
reactions, which results in distorted perceptions and memories (Mikulincer et al,
2003). Avoidant attachment style is associated with high levels of physiological
reactivity which results in vulnerability to hypertension and other cardiovascular
disease precipitated by defective physiological responses (Kim, 2006).

Anxious attachment promotes the intensification and exaggeration of undesirable

emotions, keeping the attachment system chronically activated (Cassidy & Kobak,
1988). This response is initially established by unfulfilled attempts to gain protection
and attention from the primary caregiver and leads to sustained hyper-activation of
the attachment system. This heightened vigilance for perceived threats and attention
to internal indicators of distress leads to brooding and pervasion of negative
emotions (Main & Solomon, 1986). Anxious attachment is linked to cellular immune
dysregulation through alterations in cortisol production through acute stress reactivity
(Jaremka et al, 2013; Fagundes et al, 2014)

2.3 ATTACHMENT FROM INFANT TO ADULT

Attachment theorists view secure attachment in infanthood as a predictor of

competence in adulthood (Thompson, 2000). Cummings & Davies (1994) suggest
that factors other than infant attachment to the primary caregiver can have an
influence on perpetuating attachment style - for example, marital discord, a childs
temperament, adaptability, genetics (Crawford et al, 2007; Donellan et al, 2008),
within-family attachments, and other important relational attachments. If internal
representations generated by early attachment security change over time (possibly
due to new understanding), attachment style may be altered. This concept is

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demonstrated by Hesses (1999) earned secure, where adults who were insecurely
attached as children can acquire the ability to interact with others more securely by
forming an attachment with a person who can help to disconfirm their previous
attachment model of self.

Much research on infant attachment security has focused on assessment using

strange situation with one-year olds (Ainsworth & Bell, 1970). A childs
representation of self and their relationships with others is understood as an internal
working model- the personality is thought to develop in relation to how responses
elicited from others are consistent with these internal representations of the self,
which then influences choices they make (Sroufe et al, 1999). Although Ainsworth &
Bells strange situation is a seminal work, it may be argued that, as internal working
models become a part of a childs personality around the age of three (McLeod,
2007), the effect of infant attachment style and ongoing attachment development and
influences may be more accurately determined at or after this age (Thompson,
2000).

Infanthood through to adolescence are periods of greater plasticity (malleability) for

the stress system, where early caregiving can programme basic biological responses
to threats, these periods are especially sensitive to stressors (Fraley, 2002). A
protracted activation of the stress system during these times (such as activation of
secondary defence mechanisms associated with insecure attachment) may have a
lasting and permanent effect (Charmandari et al, 2005).

Fraley & Shaver (2000) determine that adult attachment styles follow the same deep-
seated expectations or internal beliefs of caregiver or partner relationships that were
the basis for infant attachment. This view is echoed in research by Gallo & Matthews
(2006) who cite early development relationships as having pervasive and enduring
ramifications for emotion regulation, stress responses and social functioning. A
longitudinal study of insecure attachment in infancy (Moutsiana et al, 2014) also
shows correlation in enduring neural alterations of adaptive emotional regulation in
adults (Kolb et al, 2012; Burghy et al, 2012). In some studies (Hazan & Zeifman,
1999; Kirkpatrick, 1998) adult romantic attachment bonds are viewed as providing

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the same security as infant attachment with the primary caregiver. This may be
misleading, as it presumes that adults in romantic relationships are attached
securely, also it does not answer the question of how long it takes to develop these
attachment bonds and whether the people involved are already have an insecure
attachment style and whether this can be supplanted or modified by their experience
within a romantic relationship. Fraley et al (2013) question how attachment-related
functioning is transferred from primary caregivers to peers as primary attachment
figures and whether early attachment predicts competence in later relationships and
social functioning. They posit that differences in adult attachment should be viewed
in relation to both early relationships and quality of family and peer relationships.

Attachment over different domains is measured by using interviews, such as the

Adult Measure Interview (AAI) or by self-report measures of attachment i.e.
Relationship Styles Questionnaire (RSQ) as a global measure of attachment and the
Revised Experiences in Close Relationships (ECR-R) to measure romantic
attachments. It has been shown that there is little association between romantic and
global domains (Klohen et al, 2005). With regard to how adult attachment is rooted
in past attachment experiences i.e. when assessing developmental, through to adult
attachment; individual differences in affect, thoughts and behaviour should be taken
into account as they may progress differently in specific domains and globally

2.4 EMOTION REGULATION

Regulation of emotion is the process of regulating emotional arousal and expression

in a flexible way to respond to environmental demands (Thompson, 1994).
Developing in infanthood, emotion regulation and affect (especially of negative
emotions) is linked to attentional processes, cognitive skills and adaption in social
behaviour (Fox & Calkins, 2003) and is essential for adaptive functioning throughout
life (Wang & Saudino, 2011). Successful regulation in infancy is primarily dependent
upon caregiver support and flexibility in responding. This promotes security in the
availability of support from the caregiver and others in the regulation of emotional
affect (Kopp, 1982). This support allows for the transition from passive to self-
regulation (Rothbart et al, 1992) and, in secure attachment, the safety to freely

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express either negative or positive emotions. Emotion regulation is significantly
associated with stress coping, as emotion must be regulated following the emotional
reactions of stress. Repetitive or rigid patterns of emotional response i.e. fearful
responding, can become dysfunctional and restrictive, compared to more flexible
responding (Oatley & Jenkins, 1992).

Affect is the intensity of emotion: the emotions an infant displays are explicit
expressions of affect i.e. innate responses. For adults, affect is the intensity of
emotion (the readiness of the body to act) and it precedes consciousness (Shouse,
2005). Individual stress/affect response can be considered through reactivity or by
the intensity of their response to adverse or stressful situations (Mroczek et al,
2013). Repeated high reactivity can over-activate physiological systems e.g. the
HPA axis (a stress response system), the result of which is negative physical health
(Cacioppo, 1998). A 10-year longitudinal study into emotional reactivity and mortality
found that a reduction in stressor-related positive affect, rather than an increase in
negative affect, was predictive of mortality (Mroczek et al, 2015).

Research conducted by Mikulincer et al (1998) considers the link between affect

regulation and cognition, or mental representations, of how similar ones own
opinions and traits are to others (which is viewed to facilitate belonging and
validation of self). They found that insecurely attached individuals distort this
similarity to that which aligns with protecting their emotion regulating attachment-
related strategies. An interpretation of this process can be seen in Fig. 2.2, which
aims to represent the connection between cognition, affect regulation and insecure
attachment through consideration of the findings of Mikulincer et al. This leads to a
debate on whether affect regulation precedes or influences cognition. Alternatively, it
may be argued as to whether they both occur simultaneously and thereby impacting
on the regulation of emotion.

2.5 STRESS RESPONSE

The stress response re-establishes homeostasis, or allostatic balance, within the

body after exposure to external or internal (psychological) stressors (Sapolsky et al,

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2000). Selye (1979) posits that chronic exposure to stressors can trigger endocrine
exhaustion in the system by repeated triggering or chronic mobilization of the stress
response which then becomes damaging and pathogenic. Target-organ activation is
the process whereby stress response can activate, increase or inhibit an organ
system in the body such as the cardiovascular system, the skin, the gastrointestinal
system, the immune system etc. (Everly & Lating, 2013). Exposure to stress
substantially increases vulnerability of physical and mental health outcomes i.e.
autoimmune conditions and accelerated progress of chronic diseases (Pereira &
Penedo, 2005). It is hypothesised that stressors with low controllability and high
socially perceived threat, as those which may be viewed by individuals with insecure
attachment, trigger the strongest cortisol responses in the HPA axis influencing
inflammation, but have the slowest recovery to baseline levels (Dickerson &
Kemeny, 2004). The ability to return to neuroendocrine baseline in a shorter amount
of time is believed to positively influence the overall burden that stressors place on
an individual (Glaser & Kiecolt-Glaser, 2005)

FIG. 2.2: I NSECURE ATTACHMENT , AFFECT REGULATION AND COGNITION

Social Interaction

May be activated in every social

encounter (where distortions are
also exacerbated by negative
distress arousal

Create distorted cognitive representations Social comparison/evaluation

of subjective commonality with others of extent to which ones own
traits and opinions are shared
by others

Transformation of self-description and Reaction to negative affect

memories of commonality with others leading to bias and distorted
to protect attachment-related functioning social reality
i.e. avoidant underestimate commonality
to create distance from others; anxious
overestimate commonality to maximise
connectedness to others

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 Activation of defensive attachment-related strategies of
affect regulation (i.e. hyper or de-activation)

Chronic stress initiates increasing or decreasing HPA activity (and cortisol levels) by
several means including: the type of threat, the timescale from stress initiation,
emotions generated by the stressor, the ability to control the stressor and the
personality type of the individual (Miller et al, 2007). HPA activity measurement
(usually via salivary cortisol) may be an unreliable method to base assumptions upon
if only one measurement is taken, as HPA activity rises and falls throughout the day.
To optimise significantly meaningful readings, they should be taken throughout the
day over a period of several days (Stewart & Seeman, 2000).

Chronic stress can cause differences in the response of the HPA axis, the type of
health condition will mediate the impact of disease outcome i.e. early initial chronic
stress may cause vulnerability to conditions such as heart disease and metabolic
syndrome, in which cortisol is pathogenic (Smith et al, 2005), alternatively, with the
passage of time (and when cortisol levels decline to below normal), the effects of
high cortisol levels may reduce and even reverse the effects of the disease. The
consequence of deficient cortisol levels may then contribute to physical conditions
such as rheumatoid arthritis and allergic conditions (Raison & Miller, 2003; Miller et
al, 2007).

2.6 EMOTIONS & STRESS

Early life stress is associated with altered or blunted stress responses, along with
changes in the brain regions which are involved in neuroendocrine control and
emotional regulation (Heim & Binder, 2012; Grimm et al, 2014). Miller et al (2007)
posit that the nature of a threat and the emotions generated and controlled by that
threat, by an individual response, are what shape stress reaction and HPA function
(See Fig 2.3) i.e. the emotional reactions following stress encompass emotional
regulation.

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Emotion regulation is primarily comprised of the modulation of internal emotional
variations to meet external needs (Gross & Thompson, 2007). Coping with stress
involves effective internal emotion regulation, which helps to manage control of
external events (Want & Saudino, 2011). Appraisal and re-appraisal are the
processes of considering and reconsidering a situation by changing the emotional
meaning by taking into account personal capacity and resources to deal with it
(Gross, 2002). Childhood ability to regulate stress reactivity is viewed to increase in
time with their ability to regulate emotions (Stansbury & Gunnar, 1994). Antecedent-
based emotion regulation occurs before experiencing an emotion i.e. it can
determine whether an emotion will be fully experienced. It is an early emotion-
generative process where cognition is used to change the initial appraisal of the
situation, and thereby reappraise and reconstruct the emotional meanings attached,
resulting in self-regulation (John & Gross, 2004). Response-focused emotion
regulation occurs when the emotions have already been generated and include
suppression (used as a regulation strategy in avoidant attachment) which may
produce discord between inner and outer emotional experience and expression,
which can result in personal conflict, disruption of homeostasis and allostasic
overload (Yance, 2013). Individual differences to stress response and emotion
regulation can also be seen in relation to a persons perception and interpretation of
an event (Selye, 1980), leading to varying emotional and stress responses
(Roceman, 2004).

FIG 2.3: S TRESS RESPONSE AND INDIVIDUAL DIFFERENCES

Potential Stressor Events

In two categories (Girdano et al, 2009)

Biogenic Psycho-social
i.e. caffeine, nicotine
pain-involving stimuli
Cognitive/affective (emotional) appraisal

Blend of felt emotion and cognitive interpretation

establishes how a potential stressor is perceived

Stimulii OR Stressor

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 (determined by personality, learned behaviour, resources for coping
i.e. attachment style (Lazarus, 2006)

2.7 C URRENT ATTACHMENT THEORIES IN NEUROSCIENCE

Various attachment models related to neuroscience have emerged in recent

research: Fonagy et al (2011) link attachment to mentalization and stress via the
effect of two neural systems (dopamine and oxytocin). These promote stimulation of
the attachment system, the dysfunction of which affects stress regulation. Focus is
on the caregiving process and its association with social processes and personality
disorders. Vrticka & Vuilleumier (2012) agree with Fongay et als model but also
suggest that individual differences with regards to attachment style are associated
with affective/emotional and cognitive processes i.e. emotional regulation and mental
state combined with emotional evaluation such as threat/reward, avoid/approach.
They discuss involvement of specific regions of the brain incorporating serotonin,
dopamine, oxytocin and cortisol systems. Coan (2010) supports the above two
models but also introduces the concept of social proximity as an adaptive and
emotion regulating concept.

2.8 ATTACHMENT, THE AUTONOMIC NERVOUS SYSTEM (ANS) AND HPA AXIS

In order to increase understanding of connections between attachment,

psychological/emotional and biological activities i.e. the mind/body connection,
consideration should be given to the biological systems which underlie them, such as
the Autonomic nervous system (ANS) and HPA axis (part of the endocrine system)
(Berntson & Cacioppo, 2000).

The ANS is made up of the parasympathetic (PNS), which is a fight or flight

response to stressors and sympathetic (SNS) which maintains normal growth and
restores/repairs internal organs. When stressors activate the ANS, the PNS is
partially deactivated. Post-stress, the PNS restores homeostasis (balance within the
body) i.e. promotes physiological relaxation such as lowered blood pressure
(Diamond, 2001). Chronic or sustained increases in the SNS (along with concurrent

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neuroendocrine and immunological response) are detrimental to health over the
lifespan (Cacioppo et al, 1995).

Research shows that insecurely attached individuals showed increased SNS

activation (measured by blood pressure) when their partners were present rather
than absent; whereas securely attached individuals did not show reactivity in either
situation (Carpenter & Kirkpatrick, 1996). This could suggest that securely attached
individuals have an intrinsic stress buffering capabilities with regards to attachment
and relationships i.e. they may not require outward displays of support, whereas
insecurely attached may doubt the availability or support of their partner which could
promote a stress response.

Schore (2011) cites attachment figure regulation of their infants

emotional experience as playing a vital role in regulating stress systems.
Childhood attachment style is viewed as being directly related to
capabilities for, and regulation of emotion, affect and arousal, with deficits
in primary relationships being stored as automatic patterns or styles of
coping (Mikulincer et al, 1988; Diamond, 2001). Repetitive dysfunctional
interactions can have long term effects via the ANS (Carroll, 2001).
Heightened stress reactivity (seen in insecure individuals as a secondary
defence mechanism) can produce chronic increased SNS response
resulting in allostatic overload (disrupted homeostasis) with negative
health consequences (Institute of Medicine, 2001).

Psychological stress is mediated to a great degree through the HPA axis,

which is a channel for emotions, with ANS and HPA activation being
markers of stress reactivity (Cacioppo, 1994). Dysregulation of the HPA
axis through sustained exposure to stress causes chronic increase or
decrease in cortisol levels which are linked to early caregiving and stress
regulation experience and also ANS/HPA stress reactivity in adulthood
(Miller et al, 2011; Powers et al, 2006). Shirtcliffe et al (2014) consider
that the function of the HPA axis should be examined in attempting to
understand stress regulation. It is an adaptive, regulatory stress conveyor

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which helps to maintain homeostasis of the cardiovascular, ANS,
immunological and metabolic systems. Lack of adaption and disruption,
involving rising or declining cortisol reactivity or recovery is problematic
and can result in disease and illness (Yance, 2013)

2.9 D ISEASE, ILLNESS AND ATTACHMENT STYLE

As attachment mediates affect regulation before an infant can self-regulate,

emotional regulation and involuntary stress regulation are viewed to be set in
infancy, where persistently poorly regulated stress responses result in altered HPA
function and continuous, sustained exaggerated stress response (Wright, 2014) .
Physical indications of autonomic dysfunction can affect immunity through immune
suppression and increased risk of infectious disease (Picardi et al, 2007). Other
physical indicators of dysfunction include: chronic deferring of the healing system
and tissue repair i.e. compromise of the repair of stomach wall in the case of ulcers
(Ebrecht et al, 2004). A predisposition to psychosomatic illness (Maunder & Hunter,
2001) may be caused, with the possibility of the chronic stress response itself
becoming pathogenic. In Fig. 2.4 below, the strength of a stressor and the reactivity
of the stress response system, which is dependent on individual differences, are
shown by the sigmoidal curve. The right shift of the curve denotes a defective
response, with early life stress indicating a permanently altered constitutional ability
to effectively respond to stressors (Charmandari et al, 2005; Wright, 2007). The
indications are that negative developmental influences e.g. insecure attachment and
genetics, are predisposing factors for vulnerability

FIG 2.4: S TRESS RESPONSE REACTIVITY

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 (Charmandari et al, 2005); adapted from Chrousos, 1997)

Dysfunctional emotion regulation, as seen in insecure attachment, can lead to

inflexible responding, resulting in undesirable physiological outcomes (Wang &
Saudino, 2011). McEwen & Wingfield (2003) also suggest that the channel
to disease and illness can be defined as lack of adaptation (or inflexible
responding), where recovery from either rising/declining cortisol reactivity
or prolonged elevated/low levels is a problem.

Immune alterations provoked by psychological stress or stressors, i.e.

when a situation exceeds a persons evaluation of their ability to cope,
can alter health outcomes. These actual and perceived uncontrollable
stressors are damaging to the immune system and associated with
increased stress hormones, triggering significant increases in
inflammatory activity (Glaser & Kiecolt-Glaser, 2005). This echoes the
dysfunctional response to perceived threats seen in insecure attachment -
essentially chronic over-activation (anxiously attached) or increased
reactivity and physiological arousal (avoidantly attached) of the
autonomic, endocrine and immune stress-regulation systems (Diamond et
al, 2006). Diseases with an inflammatory origin include: Chronic pain,

14
diabetes, cardiovascular disease and rheumatoid arthritis. Chronic
inflammation performs a part in multiple other major diseases:
Alzheimers disease, certain cancers, asthma, arthritis and atherosclerosis
(Couzin-Frankel, 2010)

2.10 RATIONALE FOR THIS REVIEW

Based on the review of the literature, childhood attachment style is viewed as

being directly related to distinct capabilities and strategies for emotion
and arousal regulation (psychological and physiological activity and
intensity) (Mikulincer & Florian, 1998). A childs attachment with their
primary caregiver is viewed as being a mediator for effective emotional
regulation, adaptive response and stress reactivity. Bowlby (1973)
hypotheses that early attachment security forms the basis for adult
romantic attachment by the formation of basic expectations and beliefs
about relationships and the perception of a partners emotional
responsiveness and availability. Other researchers (La Guardia et al,
2000) believe that adult attachment style is based on an individuals
global working model from childhood, involving a pattern for relationship
expectations which encompasses prior and current attachment and
integrates them into a lifetime model. Dysfunctional responses to chronic,
long-term social threat-related stressors, as perceived by individuals with
insecure attachment, are believed to impact upon the autonomic,
endocrine and immune systems, with increasing risk for ill health (Couzin-
Frankel, 2010). Although high neurohormone levels, such as cortisol, were
considered a risk for health, this has now been reappraised. The path to
illness can now be linked to a lack of adaptation and inflexible responding
to cortisol levels (McEwen & Wingfield, 2003).

The following recent literature from leading researchers in the field of attachment
describe how early attachment and individual differences can impact on overall
health in adulthood: Pietromonaco et al (2013; 2015) have found evidence for links
between attachment, physiological stress response and reduced physical and

15
emotional health which can be traced from childhood through to adulthood. Fraley &
Roisman (2015) discuss two models of attachment, shaped by early experiences,
from a social functioning perspective: The Revisionist Model views early attachment
serving as the foundation of later relationship functioning, which is considered to be
capable of being altered by later experience. The Enduring Effects Model, view early
experiences as continuing to shape individual development and adaption; serving as
a scaffold and foundation. Robles & Kane (2013) concentrate on individual
differences in attachment style in romantic relationships. Links are implicated
between attachment, physiology and health with increased HPA axis response in
relationship challenges and separation. Short-term beneficial adaptive aspects are
noted (in areas such as skin recovery), whereas long-term physiological changes
may be indicators for illness. Robles & Kane (2013) make an important point when
they state that the function of the HPA axis and SNS are not sole indicators of health
outcomes, but are mediators with implications, not markers or clinical indications for
disease.

Further research is needed to examine if and how insecure attachment (through

developmental processes, emotion regulation and coping strategies) influences long-
term health outcomes (Simpson et al, 2010; Pietromonaco et al, 2013; Tacon, 2002)

During the literature scoping exercise to assess the quantity of research within this
topic area, it was found that there have been Systematic Reviews conducted in the
area of insecure attachment, but none have specifically used this format to address
confirmation of the relationship between insecure attachment and health outcomes in
adults using empirical quantitative research. This Review will aim to consider this
question and attempt to appraise the evidence and synthesise findings to provide a
possible answer to the association between insecure attachment and health
outcomes in adults.

3.0 Aims and Objectives

16
The aims and objectives are related to the reasons for, and the methods of,
undertaking the Systematic Review. To be more precise, the aims are connected to
how the research question can be answered or how the problem posed can be
solved (Bettany-Saltikov, 2012) i.e. what the Review proposes to achieve generally.
The aims are also aligned with the research question and PICO: this will be more
fully discussed in Section 4.2. The objectives will show which steps are taken to
ensure the aim will be met i.e. more specific statements linked to the investigative
procedure (UWE, 2007).

3.1 AIMS
i. To synthesize the study data to determine how insecure attachment
contributes to health outcomes in adults
ii. To examine the discourse of attachment theories and the mind/body
connection in relation to health outcomes

3.2 OBJECTIVES
i. To search for studies researching the possible connection between
insecure attachment and health outcomes in adults
ii. To evaluate the results of empirical research studies connecting insecure
attachment to health outcomes in adults
iii. To explore the possible connections between insecure attachment and
health outcomes in adults
iv. To refute or confirm connections between insecure attachment and health
outcomes in adults
v. To discuss the possible connections between affect, emotion, cognition
and stress responses with insecure attachment and resulting influence on
health outcomes in adults

4.0 Methods

4.1 S TUDY METHODOLOGY

A Systematic Review was considered the best study methodology for answering the
research question as it is a method of rigorously reviewing all empirical research
conducted within this area following a specific and comprehensive search strategy to

17
identify relevant literature (DeLuca et al, 2008). Validity of the findings and
subsequent interpretations depend on the quality and robustness of the process
which will include quality assessment and a priori selection criteria in order to avoid
bias. (Liberati et al, 2009). A systematic Review differs from Literature or Narrative
Reviews as these are considered more descriptive, with the included studies chosen
by the author or by availability. A Systematic Review encompasses transparent
methodological decisions with clearly planned and described steps: a
comprehensive search for studies to address the clearly defined research question;
a quality assessment of the studies passing the inclusion criteria and a synthesis and
discussion of the research findings (Bowland et al, 2014; Moher et al, 2007)

In the area of insecure attachment, a vast amount of information is generated by

individual research studies and peer-reviewed journal articles. As some of these
journal articles contain contrary evidence, interpretation problems may occur due to
the conflicting conclusions and variations in quality. With regard to individual
research studies - the methodology may be flawed or internal validity may be
compromised which may restrict the possible conclusions to be drawn from the
results. (CRD, 2009). Single research studies may not produce comprehensive
answers whereas a Systematic Review aims to comprehensively evaluate and
synthesise the results of all the available studies on the topic (WISC, 2014). As
noted in the Rationale (2.10) of this Review, insecure attachment has been linked to
poor health outcomes but there is also debate on whether other factors are involved
and to what extent attachment is associated. A single study on this subject will add
to the original knowledge in this area, but a Systematic Review can summarize the
collective evidence available for improved overall understanding and clarity of the
subject area. The rigour of the process involved in conducting Systematic Reviews
can provide a high quality summary, (www.kcl.ac.uk) whereby the evidence from
individual studies combined becomes more robust and can lead to greater
interpretation and understanding of the study topic.

A scoping exercise was carried out before conducting the Literature Review in order
to ascertain whether a Systematic Review had previously been executed. This
included a search of Cochrane Library Database of Systematic Reviews (Cochrane

18
Library, 2015) performed on 14.07.15 using the search terms insecure attachment
and illness, and also insecure attachment and health. There was no evidence of
a Systematic Review within this topic area, which reinforces the relevance of the
rationale for this study methodology.

4.2 REVIEW CRITERIA

A protocol is usually written before beginning a Systematic Review. This is a

proposal which outlines the prospective methods to be undertaken to answer the
Review question (Bettany-Saltikov, 2012). There are many benefits of preparing a
protocol in advance: to specify the primary outcome of importance; to provide prior
depiction of the methods used to identify relevant studies and to outline how data will
be extracted; and finally, to report the approach to summarizing the outcome data
and results (Liberati et al, 2009). The inclusion of a protocol in a Systematic Review
can contribute to internal validity by providing a transparent a priori description of the
complete approach to this process, especially if it is peer-reviewed. Bias is also
reduced, as changes or amendments made ad hoc must be justified (Higgins &
Green, 2008). This Review does not include a protocol, although attempts to reduce
bias have been shown through iterative checking of application of PICOT and
inclusion criteria, explicit reporting of each stage of the methods employed and a full
explanation of quality appraisal, data extraction and data analysis.

The Review question will form the basis of all elements of the methodology (Blakie,
2007). In order for the question to be comprehensive, but also specific, it was
developed from examination of the available research, evidence and existing
knowledge in the field of insecure attachment. This allowed assessment of what is
already known. Focus on the specific relational aspect of insecure attachment and
health outcomes, which was considered to require further investigation, was then
incorporated. To break down the elements of the research question into its
component parts and for the purpose of identifying the key concepts, a PICO format
is usually used: Population, Intervention, Comparison, Outcome (Mangam-Jeffries,
2013). This has been modified to PICOT: Population, Issue, Comparison (if there is
one), Outcome, Type of study (See Box 4.1) in order to reflect the research question

19
and the incorporation of different types of qualitative research designs. Application
of PICOT is useful to inform the development of search terms and formulation of
inclusion/exclusion criteria (Bettany-Saltikov, 2012).

BOX 4.1: PICOT F ORMAT

P Adults
I Insecure attachment or insecure attachment style
C Securely attached individuals
O Physical health status or physical illness
T Quantitative studies

Population

The population will consist of adults, defined as age 18+, there will be no upper
age limit. The research question specifies the focus on adults and, as insecure
attachment can affect an individual of any age, there is no upper age limit. All
genders will be considered for inclusion as excluding one gender may lead to bias
in terms of the question posed.
Issue

The issue is insecure attachment/insecure attachment style. The two main

categories of insecure attachment are avoidant and anxious, with personal
differences within this spectrum, as outlined in Fraleys (2010) Model of Individuals
Differences (See Fig. 1). Further recognised forms of insecure attachment will be
included: ambivalent and disorganised (Lopez & Gormley, 2002). To establish the
presence and type of insecure attachment, evidence of the use of either a verified
self-report questionnaire or specific interview type (such as the AAI Adult
Attachment Interview (George et al, 1996) will be required this will be discussed
further in Section 4.6.1.
In study designs, such as cohort, the comparison group will consist of securely
attached individuals i.e. those who do not score as insecurely attached on
completion of attachment-related questionnaires or interviews (Song & Chung,
2010). In studies such as case-control, where the sample is obtained from
individuals with/without disease or illness, the control criteria will be those who are
healthy (i.e. no evidence of physical illness or negatively altered health status) with
regard to the particular condition being addressed within the study (Lewallen &
Courtright, 1998)

Comparison
As for the criteria in issue a verified measure of attachment style will be required

20
to identify securely attached individuals. There may not be a comparison group,
i.e. in studies such as longitudinal, where one group is followed over time.

Outcome
Health status will be classified by the presence of physical illness which will be
defined as follows: verified measure of active disease; patients receiving
treatment for identified conditions; diagnosis of identified condition; presence of
physical disease; accepted measure of negatively altered health status; increased
risk for physical ill-health.

Type of Studies
The following types of quantitative research will be considered: observational:
cross-sectional, cohort, case-control and longitudinal, pre- and post, quasi-
experimental, RCT, prospective, longitudinal.

4.3: INCLUSION AND EXCLUSION CRITERIA

Inclusion and exclusion criteria are stated a priori as a guide for selection of primary
research studies to be included in the Review - this enables relevant studies to be
identified to answer the research question. Rigorous application of criteria selection,
as part of the methodological approach, will contribute to the production of a
trustworthy Review by reducing any bias in the selection of studies (Bettany-Saltikov,
2012).

INCLUSION CRITERIA

Adults
(18+, no upper age limit)
Insecure attachment
Determined by Attachment Measures (interviews or questionnaires)
Physical illness, Physiological ill-health, evidence of increased risk for
physical ill-health

21
Increased risk for physical ill health will be determined by Physiological stress
reactivity measures as a measure of vulnerability for physical health problems
(Evans et al, 2013).
Quantitative Research
This design is used to test a hypothesis by the use of structured data collection.
Quantitative research can be more generalizable than qualitative research (Shields &
Twycross, 2003). The following types of quantitative research will be considered:
observational, pre- and post, cross-sectional, case-control, cohort, longitudinal,
quasi-experimental, RCT, prospective, longitudinal
Primary Research
Comprised of original research and first-hand accounts (www.kcl.ac.uk)

EXCLUSION CRITERIA

This Review will concentrate on physical conditions, therefore the following will be
excluded:
Psychological conditions (i.e. psychosis, OCD, autism etc.); Health
seeking behaviour; Health-related coping; Social bonding; Attachment
and therapy
Illness perception
This Review is concerned with evidence of increased risk for physical ill-health or
manifestations of illness and/or illnesses which have been diagnosed, not subjective
accounts of illness
Secondary research
Studies used for data extraction within this Review will not include those where
findings are imported from other studies as they are not primary research and may
be unreliable, contain biased interpretation or unverifiable data.

4.4 S EARCH STRATEGY

A systematic and comprehensive search of primary research literature has been

conducted to identify all relevant literature available in order to answer the research

22
question. A clear and transparent audit trail is outlined to show the process
undertaken in the selection of studies for inclusion this will facilitate replication of
the process and afford the elements of integrity and trustworthiness to potential
users or readers of the Review (Moher et al, 2007). The key words and synonyms,
to form the basis of the search, were developed in order to address both specificity
(studies which are relevant) and sensitivity (potentially relevant studies). These were
refined by relating to PICOT (See Box 4.1), with reference to the inclusion and
exclusion criteria, both of which are linked to the research question (Hemingway,
2009; Bettany-Saltikov, 2012). This search strategy was informed by the expertise of
University librarians, who advised on the use of electronic databases and methods of
conducting an effective search.

As searching only one database is not sufficient to identify all the relevant studies to
be included in the Review (Yoshii et al, 2009), the following core and specialist
electronic databases were selected and searched to identify as many studies as
possible: CINAHL, MEDLINE, PsycINFO, PsycARTICLES, Scopus, Psychology and
behavioural sciences collection and EMBASE. The keyword representing the
population of interest was established, followed by identification of the issue (in this
case insecure attachment). Different key word or term variations of the issue were
identified (see fig 4.1, No 2.), then combined using the Boolean operator word OR.
This ensured that at least one of these words would be identified within the search.
The outcome keywords (health-related) were determined and combined with
Boolean operator OR, again, to identify variants (Fig 4.1, No 3). The results of
these three terms were joined together with Boolean operator term AND (See Fig
4.1 - combine the results of 1, 2 and 3). This will retrieve studies which are relevant
to the population, issue and outcome to be addressed in the Systematic Review.
(CLIO, 2015; Higgins & Green, 2008). Search words and combinations were as
follows: adult AND insecure attachment OR attachment behavio#r OR attachment
style AND physiol* OR health-related OR illness OR immun*. Truncations * or #
are used to capture spelling differences in English and American studies and to find
different variations of the word i.e. physiology, physiological. Inclusion of these
variations allowed the search to be as comprehensive as possible (Higgins & Green,
2008). The resulting search terms were then pilot-tested to ensure they captured the

23
relevant studies (Higgins & Green, 2008). The combined searches yielded 871
studies. Summary documentation of the resulting studies identified can be viewed in
Table 5.1. A detailed outline of the full search of bibliographic databases is available
in Appendix 1 and 2 to allow future reproducibility of the search strategy (Bowland et
al, 2014).

FIG 4.1: COMBINING KEYWORDS WITH BOOLEAN OPERATORS OR/AND

1. 2.
insecure attachment
Adult attachment behavio#r
attachment style

Adult & attach-

ment & health =
Relevant
Studies

Health Related
Physiol*
Health-related
Illness
Immun* 3.

(Adapted from: Higgins & Green, 2008, p. 133)

As the search has been restricted to electronic databases, this may introduce
publication bias as mainly peer-reviewed studies are likely to have been included
(University of York, 2009). The following were not carried out due to time restrictions:
hand searching of journals and literature reviews in the topic area - which can reveal
recent publications or those unindexed by electronic databases (University of York,
2009); search of grey literature i.e. OpenGrey which includes unpublished research,
conference papers, doctoral dissertations and research reports (www.opengrey.au).
Failure to search grey literature may introduce another aspect of publication bias i.e.
by providing incomplete evidence within the topic area due to lack of consideration
given to these possible sources of new research and diverse research designs
(www.york.ac.uk; Simkhada et al, 2004). There was no restriction on language
added as a limitation.
24
4.5 S ELECTION OF STUDIES

The next two stages of the study selection process were conducted to identify
potentially relevant studies to be included in the Review. They were carried out
systematically and all the steps followed were documented to improve ability of
future replication. Studies were identified by one researcher, which could potentially
introduce selection bias via subjectivity - see section 7.0 for limitations (Shea et al,
2007). As the selections were informed with reference to PICOT and the
inclusion/exclusion criteria, this may have reduced the risk of bias and error
(Bettany-Saltikov, 2012). The PICOT and selection criteria have been merged into
one table for ease of reference (See Table 4.1) this was then adopted as a tool to
pilot the eligibility of studies for inclusion and subsequently as a guide for study
selection (Bowland et al, 2014).

TABLE 4.1: PICOT AND SELECTION CRITERIA

Research Question: How does insecure attachment contribute to health outcomes

in adults? - A systematic review examining the discourse of insecure attachment and
the body/mind connection
PICOT Inclusion Criteria Exclusion Criteria
P Adults 18+ Children
I Insecure attachment determined Insecure attachment determined
by attachment measurements, by unverified measurement
either verified questionnaire or
interview
C Secure attachment (determined by Secure attachment determined by
either verified questionnaire or unverified measurement
interview) or disease-free (healthy)
O Emphasis on diagnosed physical Psychological conditions (i.e.
illness, verified measure of psychosis, OCD, autism etc.);
physiological ill-health, evidence of Health seeking behaviour; Health-
increased risk for physical ill-health related coping; Social bonding;
as the primary outcome Attachment and therapy
Illness perception
T 1.Quantitative Research 1.Qualitative Research
2.Primary Research 2.Secondary Research

25
4.5.1: F IRST STAGE SELECTION

The first stage of the selection process was based on the identification of potentially
relevant studies (see Table 5.2). Duplicate publications (n = 134) were removed
(papers reporting the same study). Throughout the search process, the researcher
was vigilant for the presence of duplicates in order to avoid possible skewing of
results, leading to an over or under-estimation of the association between
attachment and illness (Rathbone et al, 2015; Tramer, 1997). Of the remaining 722
studies, each title and abstract was scanned and the inclusion criteria applied as a
measurement of suitability. If it was determined that neither the title nor abstract met
the inclusion criteria it was discarded as it would not relevant for consideration in
answering the research question (www.york.ac.uk, 2015). Two studies in Italian were
identified by abstract, but they were discarded due to time restrictions in obtaining
and translating the full texts. It is acknowledged that this may introduce language
bias into the Review. Fifteen studies were identified as potentially meeting all the
inclusion criteria and were retained for the second stage of the selection process
(http://epb.uga.edu).

4.5.2: S ECOND STAGE SELECTION

The second stage involved obtaining full copies of all 15 studies retained from stage
one. The full-text studies were sourced through the University library, either via the
online catalogue or by written order forms. Before these could be eligible for
inclusion in the Review, the full text of each study was read and matched to the
required criteria (Bowland et al, 2014) to ensure they contained relevant information
for contributing to answering the research question. Two studies were used as pilot
examples for measuring the appropriateness of the inclusion criteria to the relevancy
to the research question and PICOT (Aslam & Emmanuel, 2010). The decision for
the inclusion or exclusion of each study is documented in the Study Selection form
(Table 5.3). Each study is numbered for ease of reference and for comparison with
PICOT and inclusion criteria. Individual studies excluded at this stage are noted in
Appendix 3, with reasons for exclusion. A PRISMA flow chart (www.prisma-

26
statement.org) records the stages of the search and selection process to show
transparency and engender trustworthiness in the process (See Fig 5.1).

Following application of the inclusion criteria to the fifteen full-text studies selected
for potential inclusion within the Review, seven were excluded (See Results Section
5.2.1 and Appendix 3). The remaining eight studies met the inclusion criteria and
were then subject to quality assessment.

4.6: ASSESSMENT OF QUALITY

Appraising the quality of the eight studies to be considered for inclusion in the
Review was undertaken to select those which show the best evidence of
methodological quality, reliability and validity through their design as, ultimately, this
will affect the results and conclusions drawn (Roland et al, 2014). Assessment of
quality identifies studies which are clinically relevant and can reveal weaknesses in
the design which may bias the results of the study (CRD, 2009). As research varies
in methodological rigour, assessing the quality of studies is essential as it allows
examination of how differences in quality and study design may explain the
differences in results (Bettany-saltikov, 2012). The internal validity of a study will
determine whether the results are of relevance and serve as a guide to interpretation
of the results (Hanney et al, 2013). Good quality design and conduct of a research
study can lead to greater trustworthiness and generalisability (external validity)
(Bowland et al, 2014).

Many tools, in the form of checklists, are available to assist in quality assessment of
individual studies. The use of checklists is a reliable method of ensuring that studies
are assessed in a standardised manner (CRD, 2009). It is important to consider the
reliability and validity of a checklist and also to adopt the most appropriate measure
for different study designs. As this Review will be assessing the quality of a variety
of study designs - case-control, cohort and cross-sectional survey - a checklist which
specifically considers each type of design will be essential. One frequently used
method of assessing the outcome of a checklist is to use a numerical scoring
system. The use of this method is questionable with regard to addressing the most
relevant aspects of an observational study, which are internal validity and bias

27
(Greenland & ORourke, 2001). Weighting of the component parts of a study by the
use of a scoring system (of a checklist) may not be precisely related to the validity of
the findings of a study. Sanderson et al (2007) propose a checklist which addresses
the most important potential sources of bias in a study. For example, the
measurement of a smaller number of key domains should be considered, applied via
a reliable and validated checklist appropriate for the study design.

Initially the STROBE checklist for observational studies was considered as a robust
and validated measure which would prove suitable for all types of studies identified
for this Review. However, Costa et al (2010) report on the misuse of this checklist as
a tool as a guideline for quality assessment in observational research. They posit
that the STROKE authors explicitly state the use for this checklist as a tool for
guidance in reporting observational studies, not for quality assessment. Additionally,
many of the items included in the checklist are exclusively associated with
transparent reporting. Considering this information, the STROBE checklist was
discounted as a possible tool for quality assessment in this Review.

Three further checklists were considered CASP (Critical Appraisal Skills

Programme) framework; Newcastle-Ottawa Quality Assessment Scale and SIGN
(Scottish Intercollegiate Guidelines Network). All three checklists were available to
address case control and cohort research study designs, although none were
available for assessing cross-sectional survey studies. To further distinguish
between the checklists, review of critical appraisal tools was consulted (Shea, 2015):
The Newcastle Ottawa Scales validity assessment is currently under development;
CASP validation process is not stated. The SIGN checklist was validated on the
themes of credibility and accountability which relate to the overall assessment of the
study. The SIGN format is easy to use and it does not rely on a numerical scoring
system but addresses whether each study meets essential criteria. This Review
employed the SIGN checklist for quality assessment with an adaptation for the cross-
sectional studies.

The SIGN checklist was piloted by the reviewer on two studies to test its usefulness
for purpose, a completed example of which can be seen in Table 4.2 below. It was

28
then applied to the remaining studies to assess their overall quality for potential
inclusion in the Review. The assessment of quality was decided on whether the
study met the criteria measured by the checklist and the overall decision on whether
to include a study in the Review was as follows:

To further clarify the definition of low quality, each research design type is further
considered regarding essential aspects of methodology which must be present in
order for the study to be considered for inclusion (see Table 5.4).

4.6.1: Q UALITY CHECKLISTS

Tables 5.5, 5.6 and 5.7 contain completed quality assessment for case-control,
cross-sectional/survey and cohort studies respectively.

++ High quality the majority of the criteria was met

+ Acceptable - most of the criteria met but may contain some flaws which
could introduce bias
0 Low quality - most criteria were not met and contained significant flaws.
Study will be discarded (SIGN, 2014).

TABLE 4.2: E XAMPLE QUALITY CHECKLIST

Cross-Sectional/Survey Studies
Study identification:
1. Rossi, P., Di Lorenzo, G., Malpezzi, M. G., Di Lorenzo, C., Cesarino, F., Faroni, J., Siracusano,
A. & Troisi, A. (2005) Depressive symptoms and insecure attachment as predictors of disability in a
clinical population of patients with episodic and chronic migraine, Headache: The Journal of Head
and Face Pain, 45(5), pp. 561-570.
2. Robles, T. F. & Kane, H. S. (2014) The attachment system and physiology in adulthood:
Normative processes, individual differences, and implications for health, Journal of
personality, 82(6), pp. 515-527.
3. McWilliams, L. A. & Bailey, S. J. (2010) Associations between adult attachment ratings and
health conditions: evidence from the National Comorbidity Survey Replication, Health
Psychology, 29(4), pp. 446.

Study Study Study

1 2 3
Rossi Robles McWilliams
2005 &Kane 2010
2014

29
Before completing checklist: Y Y
Y
1. Is the paper really a cross-sectional study?
2. Is the paper relevant to key question? Y Y Y

Section 1: Internal Validity

1.1 The study addresses an appropriate Y/N/U Y Y Y
and clearly focused question
Selection of subjects
1.2 Were participants selected randomly? Y/N/U N N Y
(may not be possible if no sampling
frame)
1.3 Was the sampling frame complete, Y/N/U Y Y Y
were omissions identified?
1.4 Are participants representative of the Y/N/U N N Y
population?
1.5 Is the target group precisely defined? Y/N/U Y Y Y
1.6 What was the response rate? Was it Y/N/U Y N** Y
adequate?*
1.7 Have steps been taken to maximise Y/N/U Y N Y
response rates?
1.8 Have the characteristics of non- Y/N/U N N N
responders been discussed? (i.e. is
there potential for bias)
Assessment
1.9 Have variables been measured by a Y/N/U Y Y One tool Y
valid tool? One tool N
1.10 If interview used as measurement, Y/N/U N/A N/A N
has training been given to maximise
standardisation?
1.11 Is the measurement tool reliable? Y Y N
(does it produce the same results on Tool for
i.e. test/retest, Cronbachs) health
status
Statistical Analysis
1.12 Confidence intervals are provided Y/N N N Y
Section 2: Overall assessment of the study
2.1 Are the results of this study Y/N/U N N Interpret N
generalizable to the target with caution
population?

2.2 How well was the study conducted to ++ + + to 0 + to 0 0***

minimise the risk of bias? 0
Y = yes N = No U = undecided
++ High quality (Retain) + Acceptable quality (Retain but address bias) 0 Unacceptable
(Reject)
*60% response rate acceptable (Fincham, 2008)
**Sample size was not discussed with regards to required sample size or required response rate
***This study was discarded due to discrepancies with effective outcome measurement tools

4.6.2: DISCUSSION OF THE QUALITY OF STUDIES

30
Within the quality checklists, the questions in section 1 refer to internal validity.
These questions ascertain whether a study is free from bias and examine the
soundness of the study design, conduct and analysis carried out to answer the
research question (Porta & Keating, 2008). Internal validity also considers whether
the observed results can be connected to the issue or exposure rather than other
causes (Carlson & Morrison, 2009). External validity is considered in Section 2 of
the checklists, which aims to ascertain whether the population of the study was
representative and therefore generalizable to other populations outside the study
(SIGN, 2014).

As the studies included in the Review are of different designs, each was considered
regarding the question of quality and how this can affect the internal and external
validity and inferences drawn from the results. Table 5.5 refers to the three case-
control studies included. A case-control study design can show associations, but not
causation and is used to generate hypotheses of potential predicators of outcome
(Greenhalgh, 1997). With regards to sampling: if cases and controls are taken from
different populations, selection bias can be introduced i.e. comparability between
cases and controls is more important than representativeness in the selection of
controls (Meirik, 2015). The use of population-based samples from i.e. specific
registers can reduce sampling bias, whereas convenience sampling may increase
bias and reduce external validity by consisting of an unrepresentative sample (Mann,
2003).

Table 5.6 addresses the three cross-sectional studies included. A cross-sectional

study cannot make assumptions of temporal relationship between the exposure and
outcome, but can make inferences regarding effects i.e. it measures prevalence and
the association between the issue/condition (Magicproject, 2014). To make
inferences, a cross-sectional study must refer to results in a comparison group and it
needs to consider whether alternative explanations have been considered (Carlson
& Morrison, 2009). Volunteer sampling may not produce subjects representative of
the population, as responders may have different characteristics to non-responders
which may introduce selection bias; a low response rate can miss differences in the

31
two response groups (Mann, 2003) - both these factors affect internal and external
validity.

The two longitudinal/Cohort studies (See Table 5.7) met all criteria for internal and
external validity, except that assessment of outcome was not blinded to exposure
status in Study 1, and in Study 2, the results were only generalizable to Caucasian
females. The lack of blinding in study 1 could introduce detection bias, where the risk
of knowledge of the type of issue i.e. attachment status secure or insecure, could
affect the subjectivity in interpreting outcome measures (Cochrane Biased Methods
Group, 2015).

Of the eight studies assessed for overall quality, three cross-sectional studies were
discarded (See Results section 5.3.1).

4.6.3: DISCUSSION OF ADULT ATTACHMENT TOOLS

Attachment is generally measured by interview or self-report questionnaire, but no

method is used universally. The main considerations for reliability and validity are
that the measurements consider the relationship focus, attachment types,
dimensions and attachment constructs (Ravitz et al, 2010). Both self-report and
interview techniques measure defensive processes, emotional regulation, social
interaction awareness and behaviour in close relationships (Shaver & Mikulincer,
2003), although the emphasis may vary.

A limitation of self-report questionnaires is the fact that they cannot measure

subconscious defensive strategies (which may distort responses). They mainly
concentrate on conscious perception of how individuals view themselves at the
present time with regards relationships with others (Milulincer et al, 2007).
Interviews such as the AAI (Adult Attachment Interview) can expose attachment
activation or triggers linked to attachment experience; although the limitation of
interviews is the extensive resources, time and training needed to administer them
(Ravitz et al, 2010).

32
Questionnaires can include solely categorical measures or both dimensional and
categorical. Dimensional measures include how one perceives oneself and others
i.e. negative sense of ones own value or whether others are trustworthy.
Categorical measures contain distinct cut off points for each category i.e. secure,
avoidant, anxious etc. The most frequently used measures of adult attachment
include the ECR (Experiences in Close Relationships) and the revised version -
ECR-R (Shi et al, 2013). More recently the ECR-RS (Relationship Structure) has
become available, which assumes attachment in 4 kinds of relationships mother,
father, romantic and friends. Other commonly used questionnaires, used in
psychosomatic research, are AAI, RQ (Relationship Questionnaire), AAS (Adult
Attachment Scale) and ASQ (Adult Style Questionnaire) (Ravitz et al, 2010).

Attachment may be viewed as related to individual differences over different domains

and in different relationships i.e. partner, friend etc. Fraley et al (2011) question
whether measures for self-reported attachment style are adequate unless they
clearly state which specific relationship type it is measuring. A further view on
attachment measurement is posited by Ravitz et al (2010), where they believe
attachment behaviour/activation is seen as related to specific or perceived threats or
triggers, while attachment patterns are the consistent behaviour related to the trigger
situations. Attitudes to relationships (i.e. perception of others trustworthiness and the
selfs lovability) guide attachment behaviour and patterns some measures are
more sensitive than others in detecting these.

4.7 DATA EXTRACTION

A bespoke form was created to standardise the type of data extracted and provide
consistency within the Review. A standardised data extraction form promotes a
reduction in bias and an improvement in validity and reliability. By constructing and
applying a data extraction form, a clear audit trail between the study papers, the
initial understanding of the papers, the description of the component parts and
synthesis of the findings can be followed (CRD, 2008). The form was designed to
extract relevant data to provide information on outcomes necessary for Review
synthesis and to address the research question (Kitchenham, 2004). The data
extraction form also enabled the collection of study characteristics, outcome

33
measures and results in a format which is reproducible and provides a general
overview of each study included in the Review (Handoll & Smith, 2004).

When undertaking data extraction it is usual practice for a minimum of two

researchers to be involved in the extraction process: either with one to extract the
data and the other to independently check the data extraction forms for
completeness and accuracy; or, two researchers independently executing data
extraction, with any disagreement resolved by a third researcher. Due to time
constraints and lack of resources, only one researcher will carry out the data
extraction. It is acknowledged that this could introduce bias and the possibility of
errors (York.ac.uk, 2015). To enhance the accuracy and completeness of data
extraction, the initial process was supplemented with a subsequent review and
cross-checking of the data extracted to identify possible inconsistencies and
omissions.

The data extraction form was piloted on one study (See Table B below) to ensure all
relevant data was captured and to identify data which may have been missing or was
surplus to requirements (Boland et al, 2014; Higgins & Green, 2011). Data was
extracted from the five studies included in the Review, fully completed forms can be
viewed in Appendix 5-9. An example of the data extraction table can be seen below
(Table 4.3).

TABLE 4.3: E XAMPLE OF DATA EXTRACTION FORM

Study 1
Bibliographic details of study Picardi, A., Miglio, R., Tarsitani, L., Battisti, F., Baldassari, M.,
Copertaro, A. Mocchegiani, E, Cascavilla, I. & Biondi, M. (2013)
Attachment style and immunity: A 1-year longitudinal
study, Biological psychology, 92(2), pp. 353-358
Date of extraction 3rd August 2015
Purpose of Study To establish the reliability of the association between
attachment-related avoidance and immunity
Study setting Ancona, Italy
Local National Health Service Unit
Study design Longitudinal study
Inclusion/exclusion criteria <60 years old, in current job for 2 years, absence of infectious
diseases and chronic medical conditions, no history of major
psychiatric disorders and no current treatment with drugs
affecting the immune system
Population Sample size: 65.

34
 Caucasian female nurses.
Mean age 36.8 7.4 years (24-58)
Sample and recruitment Random (probability) sample recruited from National Health
Service Unit
Response rate 100% (Study was incorporated into periodic occupational health
examinations)
Blinding Immune assays were performed blinded to all other measures
collected
Identification of confounders Males were excluded, due to small number of male staff and
possibility of confounding effect of gender
Other Variables measured and Alexithymia scale TAS-20) difficulty identifying feelings,
controlled for Percieved Stress Scale (PSS), Scale of Perceived Support
(MSPSS), alcohol, tobacco, NSAIDS (pills per week), sleep,
exercise
Measurement tool for Experiences in Close Relationships (ECR)
attachment Measured at baseline
Measurement tool for Natural killer cell cytotoxicity (NKCC) and Lymphocyte
disease/illness or increased risk proliferative response (LPR) immunity measurements
for ill-health Measured at baseline, 4, 8 and 12 months follow up
Ethics Informal authorization by local Ethical Committee
Results High attachment-related avoidance was found to be
independently associated with lower NKCC levels and
corroborate the link between attachment and altered immune
function.

4.8 DATA ANALYSIS METHODS

The results of the individual Review studies were synthesised to provide an overview
of the collection of all the findings. Consideration was given to the various possible
types of synthesis, and which would be most appropriate for this Review:

Meta-analysis is a statistical approach to data analysis where numerical results from

a number of separate studies are combined. The advantages of undertaking a meta-
analysis are: an increase power and precision of the results, along with a
summarised statistic of the overall effectiveness of the variables considered (Higgins
& Green, 2008). The use of meta-analysis allows the pooling of results from small
studies, which may have results showing minimal significance. The effects of this
pooling can result in an increase in power and lessen the possibility of a Type II error
(which is when the results show a false negative effect) (Pettrigrew, 2003). The
disadvantage of meta-analysis is that it does not take into account variations in the
quality of studies included, which can lead to bias in the conclusions reached
(Pettigrew, 2001)

35
A meta-analysis can only be considered if the Review studies are adequately
homogeneous (similar) i.e. in terms of issues and outcomes measured, or if an
average of the results would be relevant (EBBP, 2007). This method of synthesis will
not be suitable in this Review, as statistical pooling will not be possible due to the
heterogeneity of the individual studies included (Kulinskaya et al, 2011). Therefore,
a narrative synthesis approach was taken. This method synthesises the results from
multiple studies in a predominantly narrative form i.e. using words and text, in order
to explain and summarise the findings (Popay et al, 2009). One disadvantage of
narrative synthesis of individual heterogeneous studies is the greater risk of
introducing a Type II error. This may occur as some small studies may not have the
power to detect a statistically significant outcome, thus leading the reviewer into
presuming the study produced no observable results (Pettigrew, 2003). To address
the issue of the effectiveness of narrative synthesis methods in Systematic Reviews,
Rogers et al (2009) developed guidance on the execution of narrative synthesis by
comparing the application of meta-analysis and narrative synthesis to the same
studies the different approaches were then compared. It was found that both
methods resulted in a broadly similar outcome conclusion.

A best-evidence narrative synthesis was carried out. In preparation, the methods

section of this Review describe, a priori how studies were selected for inclusion in a
thorough, transparent and unbiased manner, giving reasons for decisions made (see
7.0: Limitations). The aim is to provide readers with an indication of what conclusion
the evidence points to and whether the results, discussion and justified conclusions
can answer the research question (Slavin, 1995). A formula for best-evidence
synthesis is included to allow the process to be reproduced (See Fig 4.2)

36
FIG 4.2: DATA SYNTHESIS PROCESS

(Adapted from 5 Observational

Rogers et al, 2009) Studies

Textual Description

Groupings & Themes

Exploring
relationships within
and between the
studies
Best evidence
synthesis

Reflecting critically
on the synthesis
Conclusions and
recommendation

5.0 Results

The steps in the process of undertaking this Systematic Review are

outlined below, with the results from each stage presented in narrative
and table forms.

A clear and structured research question was posed: How does insecure
attachment contribute to health outcomes in adults? From this question a PICOT
format was constructed to outline the Population, Issue, Comparison, Outcome and
Type of research studies to be considered for inclusion in the Review. Following the
factors identified in PICOT, inclusion/exclusion criteria were specified a priori to
conducting a comprehensive search in order to identify studies relevant to
addressing the research question.

37
To comprehensively capture all studies within the subject area, electronic databases
were identified and searched using Boolean Operators and key search words to
identify relevant and potentially relevant studies (See Appendix 1 & 2 for the
keywords and synonyms used). The search resulted in a total of 871 studies to be
considered for inclusion in the Review. The databases searched, the number of
studies identified within each database and the subjects covered by these
databases, can be viewed in Table 5.1.

5.1: FIRST STAGE SELECTION OF STUDIES

The first stage of the selection process involved removing duplicates from
the search results in order to avoid screening the same studies multiple
times. All identified studies were then screened by title and abstract by
one researcher to measure relevancy of each study to the research
question, PICOT and inclusion/exclusion criteria. This strategy resulted in
the removal of 134 duplicates and 722 studies by title and abstract (See
Table 5.2). The remaining 15 studies were carried through to the second
selection stage where the full text papers for each study were obtained
(See Box 5.1 for further details of the 15 studies identified).

TABLE 5.1: S UMMARY OF RESULTS OF PRELIMINARY SEARCH USING KEYWORDS

Database Date Studies Health Subjects Covered by

& date range searche identified Database
d
CINAHL 15/07/15 121 Nursing, Allied Health Journals
1957-20155
MEDLINE 15/07/15 237 Biomedical Literature
1957-20155
PsycINFO 15/07/15 270 Behavioural science and mental health;
1957-20155 psychiatry, psychology and sociology
PsycARTICLES 15/07/15 23 Psychology
1957-20155
Psychology & 15/7/15 95 Emotional and behavioural
Behavioural characteristics; psychology; psychiatry
Sciences
1957-20155

38
SCOPUS 14/07/15 13 Social sciences; medicine; psychology;
2000-2015 pharmacology
EMBASE 13/07/15 112 Biomedical; pharmaceutical; psychiatry
1974-2015
5 Limitations on date were initially applied to possibly reduce the studies to
up-to-date research but, as the difference in studies found was negligible,
it was decided to leave the original default date setting on these five
databases. The date range is compatible over all five databases as they
were all incorporated into one search on EBSCOhost by selecting choose
databases and selecting all five.
The default date setting was 2000-2015. A limited was piloted: 1970-
2015 in order to find all relevant studies, but the result of hits was the
same.

TABLE 5.2: F IRST SELECTION STAGE

Database Search Hits Duplicates Read and To read

& date range date Removed discarded full study
by Title and
Abstract
CINAHL 15/07/15 121 4
1957-2015

MEDLINE 15/07/15 237 7

1957-2015

PsycINFO 15/07/15 270 1

1957-2015 117 616

PsycARTICLES 15/07/15 23 1
1957-2015

Psychology & 15/07/15 95 0

Behavioural
Sciences
Collection
1957-2015

SCOPUS 14/07/15 13 5 7 1
2000-2015

EMBASE 13/07/15 112 12 99 1

39
1974-2015

TOTAL (of all

databases 871 134 722 15
combined)

BOX 5.1: S TUDIES IDENTIFIED FOR INCLUSION IN STAGE TWO

1. Gick et al (2010) Insecure attachment moderates women's adjustment to

inflammatory bowel disease severity
2. Picardi et al (2005) Stress, social support, emotional regulation, and
exacerbation of diffuse plaque psoriasis
3. Gouin et al (2009) Attachment avoidance predicts inflammatory responses to
marital conflict
4. McWilliams et al (2010) Associations between adult attachment ratings and
health conditions: evidence from the National Comorbidity Survey Replication
5. Puig et al (2013) Predicting adult physical illness from infant attachment: A
prospective longitudinal study
6. Rossi et al (2005) Depressive symptoms and insecure attachment as predictors
of disability in a clinical population of patients with episodic and chronic
migraine
7. Barbosa et al (2011) Alexithymia in chronic urticaria patients
8. Agostini et al (2010) Adult attachment and early parental experiences in
patients with Crohns disease
9. Scheidt et al (2000) Attachment representation and cortisol response to the
adult attachment interview in idiopathic spasmodic torticollis
10. Caplan et al (2014) Attachment, Childhood Abuse, and IBD-related Quality of
Life and Disease Activity Outcomes
11. Ercolani et al (2004) Gastrooesophageal reflux disease: Attachment style and
parental bonding 1
12. Picardi et al (2007) Attachment security and immunity in healthy women
13. Maunder et al (2005) Attachment insecurity moderates the relationship between
disease activity and depressive symptoms in ulcerative colitis
14. Picardi et al (2013) Attachment style and immunity: A 1-year longitudinal
study
15. Robles et al (2013) Attachment, skin deep? Relationships between adult
attachment and skin barrier recovery

40
5.2: SECOND STAGE SELECTION OF STUDIES

In the next step of the Review process, the full text of each identified
study was read. The inclusion criteria were then applied to provide
identification of studies which would be relevant to answer the research
question (See Table 5.3).

TABLE 5.3: S TUDY SELECTION FORM

PICOT Inclusion Criteria Study paper number

1 2 3 4 5 6 7 8 9 1 11 1 13 14 15
0 2
Population Adults 18+ Y Y Y Y Y N Y Y Y Y Y Y Y Y Y
Issue Insecure attachment Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
(measurement)
Compariso Secure attachment N Y Y Y Y Y Y Y Y Y Y Y Y Y Y
n
(n/a in
longitudinal
)
Outcome Diagnosed or verifiably N N N Y Y Y N Y Y N Y Y N Y Y
(primary) measured physical ill-
health or increased risk
Exclusion:
Psychological conditions,
subjective accounts of
illness, health seeking
behaviour; Health-related
coping; Social bonding;
Attachment and therapy
Illness perception
Type-study Quantitative Primary Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
Research
Action* Y, N or U N N N Y Y U N Y Y N Y N N Y Y
*
*Action for inclusion or exclusion: Y = Yes, N = No, U = undecided
* Study number 12 is a duplicate of study number 14

41
5.2.1: S TUDIES EXCLUDED AT STAGE TWO

Seven studies did not meet the criteria and were excluded (See Appendix
3):

Study No. 12 (Picardi et al, 2007) was excluded as it was a duplicate of a previous
study which had been conducted six years earlier. The study researchers used the
same data set and focused on the same associations. Their reasons for extending
and updating their previous study were cited as the reliance on a single measure of
one of the variables as posing a considerable limitation. The most recent study was
retained for inclusion in the Review as this was the more robust and up-to-date.
Study No. 1 (Gick et al, 2010) was excluded as the direction of focus was related to
perceived social support and coping strategies of individuals who were already
suffering with the condition, rather than disease/condition as an outcome or
predicted increased risk for developing the disease.

Study No. 2 (Picardi et al, 2005) was not considered suitable for inclusion as it
focused on exacerbation, not onset, of the condition. The exclusion of study No. 3
(Gouin et al, 2009) was due to lack of evidence (with regards the measurement
instrument) to show increased risk of ill-health. The research in this study sought to
link attachment avoidance, inflammatory responses and martial conflict. Increased
IL-6 plasma levels were used as an indicator of inflammatory response leading to
increased risk of developing cardiovascular disease and other conditions (Ridker et
al, 2000). IL-6 is not necessarily an indication/predicator of ill-health: Steerberg et
al, 2000 show increased IL-6 levels having a beneficial role through growth factor
abilities. Study No. 7 (Barbosa et al, 2011) was excluded due to attachment style
being examined as the secondary predicator. The main goal of this research was to
consider the prevalence of alexithymia in individuals with the health condition
(chronic urticaria) and to consider psychological variables associated with
alexithymia. Study No. 10 (Caplan et al, 2014) was excluded as the primary purpose
was to study the relationship between childhood abuse and overall activity of
disease, with attachment as a moderator i.e. the relationship between attachment
and disease was not the primary outcome. The final study, No. 13 (Maunder et al,

42
2013) was excluded due to the primary focus falling on the associations between
depression and ulcerative colitis disease activity, with attachment serving as a
moderator variable i.e. influencing the strength between the dependent and
independent variables (WISC, 1999).

5.3: QUALITY ASSESSMENT

The remaining eight studies were assessed for evidence of methodological quality,
reliability and validity through their design using a modified version of Scottish
Intercollegiate Guidelines Network (SIGN) Quality Assessment checklist. The
studies included 3 case-control designs, 3 cross-sectional and 2 longitudinal/cohort.
The definition of key quality issues for each study design classification can be
viewed in Table 5. A different checklist was used for each design type: Case-Control,
Cross-Sectional and Longitudinal/Cohort. A synthesis of the results of the quality
checklists, for ease of reference, can be seen in Table 5.8. Of the eight studies, three
were excluded due to poor quality issues. A Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) flow chart documents the complete selection
process (See Fig 5.1). The final selection comprised five studies to be incorporated
into the Review.

TABLE 5.4: DEFINITION OF ACCEPTABLE QUALITY

Cohort/longitudina Cohort identification

l Confounding is addressed
Follow up
Exposure measurement and outcome
measure
Case Control Definition of source population
Identification of cases/identification of Clear, well-defined question
controls Correct study design
Confounding is addressed (Greenhalgh, 1997)
Exposure measurement and outcome
measurement Alternative explanations have
Cross-sectional Representative random sample been ruled out
Sample size recruited stated/response (Carlson & Morrison, 2009)
rate stated
Measurement of variables
Reliability of measurement tool
(www.magicproject.org;

43
 www.sign.ac.uk)

TABLE 5.5: QUALITY ASSESSMENT FOR CASE CONTROL STUDIES

Case Control Studies

Study identification:

1. Ercolani, M., Farinelli, M., Trombini, E., & Bortolotti, M. (2004) Gastrooesophageal reflux disease:
Attachment style and parental bonding 1, Perceptual and motor skills, 99(1), pp. 211-222.
2. Agostini, A., Rizzello, F., Ravegnani, G., Gionchetti, P., Tambasco, R., Straforini, G., Ercolani, M. &
Campieri, M. (2010) Adult attachment and early parental experiences in patients with Crohns
disease, Psychosomatics, 51(3), pp. 208-215.
3. Scheidt, C. E., Waller, E., Malchow, H., Ehlert, U., Becker-Stoll, F., Schulte-Mnting, J. & Lcking,
C. H. (2000). Attachment representation and cortisol response to the adult attachment interview in
idiopathic spasmodic torticollis, Psychotherapy and psychosomatics, 69(3), pp. 155-162.

Section 1: Internal Validity Study Study Study

1 2 3
Scheid Ercolan Agnostin
t i i
2000 2004 2010
Before completing checklist:
Y Y Y
1. Is the paper really a case-control study?
Y Y Y
2. Is the paper relevant to key question?
3.

1.1 The study addresses an appropriate and Y/N/U Y Y Y

clearly focused question
Selection of subjects
1.2 The cases and controls are taken from Y/N/U N Y N
comparable populations
1.3 The same exclusion criteria are used for both Y/N/U Y Y Y
cases and controls
1.4 Indication of what percentage of each group Y/N/U Y Y Y
(cases and controls) participated in the study?
1.5 Comparison is made between participants and Y/N/U Y Y Y
non-participants to establish their similarities or
differences.
1.6 Cases are clearly defined and differentiated Y/N/U Y Y Y
from controls
1.7 It is clearly established that controls are non- Y/N/U Y Y Y
cases
Assessment
1.8 Measures will have been taken to prevent Y/N/U Y Y N
knowledge of primary exposure influencing
case ascertainment.
1.9 Exposure status is measured in a standard, Y/N/U Y Y Y
valid and reliable way
Confounding
1.10 The main potential confounders are identified Y/N/U Y Y Y
and taken into account in the design and

44
 analysis.
Statistical Analysis
1.11 Confidence intervals or means are provided Y/N Y Y Y
Section 2: Overall assessment of the study
2.1 Is there evidence of an association between Y/N/U Y Y Y
exposure and outcome?
2.2 Are the results of this study generalizable to the Y/N/U U Y U
target population?
2.3 How well was the study done to minimise the ++ + ++ ++ +
risk of bias or confounding? 0
Y = yes N = No U = undecided
++ High quality (Retain) + Acceptable quality (Retain but address bias) 0 Unacceptable (Reject)

TABLE 5.6: QUALITY ASSESSMENT FOR CROSS-SECTIONAL /SURVEY STUDIES

Cross-Sectional/Survey Studies
Study identification:

1. Rossi, P., Di Lorenzo, G., Malpezzi, M. G., Di Lorenzo, C., Cesarino, F., Faroni, J., Siracusano,
A. & Troisi, A. (2005) Depressive symptoms and insecure attachment as predictors of disability in a
clinical population of patients with episodic and chronic migraine, Headache: The Journal of Head
and Face Pain, 45(5), pp. 561-570.
2. Robles, T. F. & Kane, H. S. (2014) The attachment system and physiology in adulthood:
Normative processes, individual differences, and implications for health, Journal of
personality, 82(6), pp. 515-527.
3. McWilliams, L. A. & Bailey, S. J. (2010) Associations between adult attachment ratings and
health conditions: evidence from the National Comorbidity Survey Replication, Health
Psychology, 29(4), pp. 446.

Study Study Study

1 2 3
Rossi Robles McWilliams
2005 &Kane2014 2010
Before completing checklist: Y Y
Y
7. Is the paper really a cross-sectional study?
8. Is the paper relevant to key question? Y Y Y

Section 1: Internal Validity

1.1 The study addresses an appropriate Y/N/U Y Y Y
and clearly focused question
Selection of subjects
1.2 Were participants selected randomly? Y/N/U N N Y
(may not be possible if no sampling
frame)
1.3 Was the sampling frame complete, Y/N/U Y Y Y
were omissions identified?
1.4 Are participants representative of the Y/N/U N N Y
population?
1.5 Is the target group precisely defined? Y/N/U Y Y Y
1.6 What was the response rate? Was it Y/N/U Y N** Y
adequate?*
1.7 Have steps been taken to maximise Y/N/U Y N Y

45
 response rates?
1.8 Have the characteristics of non- Y/N/U N N N
responders been discussed? (i.e. is
there potential for bias)
Assessment
1.9 Have variables been measured by a Y/N/U Y Y One tool Y
valid tool? One tool N
1.10 If interview used as measurement, Y/N/U N/A N/A N
has training been given to maximise
standardisation?
1.11 Is the measurement tool reliable? Y Y N
(does it produce the same results on Tool for
i.e. test/retest, Cronbachs) health
status
Statistical Analysis
1.12 Confidence intervals are provided Y/N N N Y
Section 2: Overall assessment of the study
2.1 Are the results of this study Y/N/U N N Interpret N
generalizable to the target with caution
population?
2.2 How well was the study conducted to ++ + + to 0 + to 0 0***
minimise the risk of bias? 0
Y = yes N = No U = undecided
++ High quality (Retain) + Acceptable quality (Retain but address bias) 0 Unacceptable
(Reject)
*60% response rate acceptable (Fincham, 2008)
**Sample size was not discussed with regards to required sample size or required response rate
***This study was discarded due to discrepancies with effective outcome measurement tools

TABLE 5.7: QUALITY ASSESSMENT FOR COHORT STUDIES

Longitudinal /Cohort Study

Study identification:

1. Puig, J., Englund, M. M., Simpson, J. A. & Collins, W. A. (2013) Predicting adult
physical illness from infant attachment: A prospective longitudinal study, Health
psychology, 32(4), pp. 409.
2. Picardi, A., Miglio, R., Tarsitani, L., Battisti, F., Baldassari, M., Copertaro, A.
Mocchegiani, E, Cascavilla, I. & Biondi, M. (2012) Attachment style and
immunity:A 1-year longitudinal study, Biological psychology, 92(2), pp. 353-358

Section 1: Internal Validity Study Study

1 2
Puig, Picardi
2013 2012
Before completing checklist:
Y Y
1. Is the paper really a longitudinal/cohort study?
Y Y
2. Is the paper relevant to key question?

1.1 The study addresses an appropriate and clearly Y/N/U Y Y

46
 focused question
Selection of subjects
1.2 The two groups studied are selected from source Y/N/U Y N/A One
populations comparable in all respects other than the group
factor under investigation only
1.3 Indication of the percentage of people in each group Y/N/U Y Y
who took part in the study One
group
1.4 Possibility of eligible participants having the outcome Y/N/U Y* Y
at enrolment is considered and accounted for in
analysis
1.5 Drop-out rate of participants recruited into each arm of Y/N/U Y Y
the study was considered One
group
Assessment
1.6 The outcomes are clearly defined Y/N/U Y Y
1.7 Assessment of outcome is blind to exposure status? Y/N/U N Y
Where blinding is not possible, recognition that this
could have influenced assessment of outcome
1.8 The method of assessment of exposure is Y/N/U Y Y
reliable/valid
1.9 Exposure level or prognostic factor is assessed more Y/N/U Y Y
than once
Confounding
1.10 The main potential confounders are identified and Y/N/U Y Y
taken into account in the design and analysis.
Statistical Analysis
1.11 Confidence intervals are provided Y/N Y Y
Section 2: Overall assessment of the study
2.1 Is there evidence of an association between exposure Y/N/U Y Y
and outcome?

2.2 Are the results of this study generalizable to the target Y/N/U Y U**
population?
2.3 How well was the study done to minimise the risk of ++ + ++ ++
bias or confounding? 0
Y = yes N = No U = undecided
++ High quality (Retain) + Acceptable quality (Retain but address bias) 0
Unacceptable (Reject)
*Participants were to be first born children of pregnant women
** Generalisable to the sample population Caucasian female nurses

(Checklists adapted from www.sign.ac.uk)

TABLE 5.8: S YNTHESIS OF QUALITY ASSESSMENT RESULTS

Cross-Sectional Cohort/Longitudinal Case-Control

Rossi et Robles & McWilliam Puig et al Picardi et al Scheidt Ercolani Agnostini

al Kane s et al et al et al et al

47
 2005 2014 2010 2013 2012 2000 2004 2010

0 0 0 ++ ++ ++ ++ +

++ High quality the majority of the criteria was met

+ Acceptable - most of the criteria met but may contain some flaws which could introduce bias
0 Low quality - most/relevant criteria were not met and contained significant flaws. Study will
be discarded
(SIGN, 2014)

FIG 5.1: PRISMA F LOW CHART

Records identified through Additional records identified

database searching through other sources
(n = 871 ) (n =0 )

Records after duplicates removed

(n = 722 )

Records screened by Records excluded by

title and abstract title and abstract
(n=722) (n=706)

Full-text articles Full-text articles

assessed for eligibility excluded, with
(n=15) reasons (n=7)
Articles excluded
Articles included in at quality
quality assessment assessment stage
stage (n=8) (n=3)

Studies included in (Adapted from:

synthesis (narrative
http://www.prisma-
analysis)
statement.org/statement.htm)
(n = 5 )
5.3.1: S TUDIES EXCLUDED AT QUALITY ASSESSMENT STAGE

These studies were discarded at this stage as best evidence syntheses will be
carried out on studies providing the best evidence regarding their methodology and
quality of conduct. The lower quality of these studies may affect the integrity of the

48
synthesis. The studies to be included in the Review have been identified via clearly
stated, a priori, inclusion criteria and quality assessment, which is transparent and
explicit. Slavin (1995) states that one of the main reasons for including all studies,
regardless of their quality, is usually stated as being a safeguard against researcher
bias regarding which studies are high and low quality (See Appendix 4).

The McWilliams et al (2010) study was discarded due to flaws in the use of
measurement tools. The first tool used to measure chronic health conditions was an
un-validated lifetime experiences with chronic conditions questionnaire with yes/no
answer and did not confirm diagnoses. This measurement was therefore considered
unreliable. The second measurement tool, the World Health Organisation
Composite International Diagnostic Interview (CIDI) requires training at a WHO-
authorised CIDI training centre (WHO, 2014). There was no evidence that the
interviews had been conducted by a trained investigator. As valid and reliable
measurement tools are essential components of a well-conducted cross-sectional
study, the quality of this study was considered unacceptable.

The second study discarded was Rossi et al (2005). In the application of exclusion
criteria stage (see Table 4), this study did not meet the population criteria which is
adults 18+ (this study included adults 16+), although this was not seen as a major
flaw and the study was carried through to quality appraisal. At this stage it was
noted that the participants were not randomly selected and therefore possibly not
representative of the population, only to the specific clinic they were selected from.
Non-responders were not discussed and therefore it is not evident what their
characteristics were and whether this could bias the results (Levin, 2006). No
confidence intervals were provided to aid interpretation of the results which could be
expected to be likely if the study was to be repeated i.e. when generalising results
(IWT, 2007). Other variables influencing migraine severity, such as dietary and
hormonal, were not considered (NHS Choices, 2014) which could be potential
confounding elements when viewing the results.

The third study discarded was the Robles et al (2014) study due to the selection bias
which resulted from non-random sampling in a small area surrounding a university

49
through flyers and online advertisement. This sampling method introduces response
bias and does not allow generalisation due to high response of educated participants
of a certain age, living in a particular place. Non-responders tend to include those in
a lower socio-economic background with lower educational levels (Webber, 2011).
The study lacked confidence intervals (as noted above in the Rossi et al study).
Neither response rate nor non-responders were discussed: there is no indication of
the expected or desired response rate these factors introduce the same bias as
seen in Rossi et al (2005) above. The study states that 34 couples were recruited, as
this is a small sample it could introduce low statistical power into the study i.e. a
statistically significant finding may not reflect a true effect (Button et al, 2013). It is
possible that a sample size calculation was carried out by the researchers, but a
discussion of the steps or requirements to maximise response rates was not
provided.

5.3.2: DISCUSSION OF QUALITY OF INCLUDED STUDIES

Rigorous studies are more likely to show more accurate results; the credibility of the
Review may be affected via poor methodology within the primary studies included
(Bettany-Saltikov, 2012), therefore bias has been assessed within the included
studies to enable conclusive reporting and inferences from the results.

Case-control studies can show association by measuring the prevalence of the

exposure and can generate hypotheses of potential predicators of outcome i.e. is
attachment a predicator (risk factor) for physical illness? Recall bias, which is an
individuals ability to accurately recall a past exposure, is not a real problem in these
case-control studies as the measurement for risk factor is attachment style: a
biopsychosocial trait (Health Knowledge, 2011). Selection bias in the case-control
studies could have been introduced as only cases were selected from
clinics/hospitals, whereas controls were selected by convenience sampling from the
general population in studies 3 (Scheidt et al, 2000) and 5 (Ercolani et al, 2004).
These controls therefore may not be representative of the population the cases
were selected from, although it may have been difficult to find controls in hospital or
clinic settings. This affects external validity, where generalisation to the larger

50
population may not be possible, but inferences can be made and hypotheses formed
(Mann, 2003). Controls in all case-control studies were matched to ensure they
were similar in specific characteristics, thereby improving internal validity that is,
the issue/intervention, rather than other factors, is associated with the outcome
(Carlson & Morrison, 2009). Study 5, a case-control introduced a protocol deviation,
allowing accompanying person into the participant interview this could have biased
and skewed the results by causing participants to give different answers to the
questions or to feel more confident within the interview. Also, other risk factors for
Gastroesophageal Reflux Disease (GERD) such as obesity, alcohol, tobacco and
pregnancy were not measured which could bias the strength of association found
between attachment status and GERD (Alan, 2008). This studys results were
interpreted with caution.

In study 2 (Puig et al, 2013), a self-report health questionnaire was used as the
outcome measure but the researchers could not confirm these against medical
records. This is cited as a limitation, with the self-reported health responses being
used as a proxy measure of participants actual health. The study reported attrition
rates and the reasons for them, reducing attrition bias (bmg.cochrane.org, 2015). As
participants were followed from birth to age 32, it is possible for the study to show
that attachment style (cause or risk factor) precedes the outcome (physical illness);
the study can also show incidence (rate of occurrence). Wide confidence intervals
(CI) in this study could be the result of insufficient data i.e. sample size too small, or
the data could be too variable for a precise estimate (Kalinowski, 2010). Study 1
(Picardi et al, 2012) had no attrition rates from a sample of Caucasian females,
therefore the results can only be generalised to this similar population. In both
longitudinal studies internal validity was increased as participants were similar at
baseline, which allows the outcome to be associated with the effects of the
intervention i.e. attachment status. Internal validity was increased in study 1 as
researchers collecting immunity data were blind to the attachment status of
participants, thereby reducing detection bias (phcochrane.org, 2015). External
validity was increased as follow up occurred at 3 points in time, which provided a
greater predication of effect over time rather than a measurement at only one point in
time and is therefore more generalizable (Rothwell, 2006).

51
5.4: DESCRIPTION OF STUDIES INCLUDED IN THE REVIEW

The research design and purpose of five studies included in the Review are as
follows: Study 1 (Picardi et al, 2012) is a prospective longitudinal study and aims to
establish an association between avoidant attachment and immune function through
the measurement of Natural Killer Cell Cytotoxicity (NKCC) and Lymphocyte
Proliferative Response (LPR). Study 2 (Puig et al, 2013) is a prospective
longitudinal cohort study which examined the links between attachment classification
in childhood and physical illness, inflammation-related illness and nonspecific
symptoms in adulthood.

Studies 3, 4 and 5 are all case-control. Study 3 (Scheidt et al, 2000) was
investigating individual differences in attachment and its impact on cortisol response
to psychosocial stress in idiopathic torticollis (IST). An idiopathic disease is one in
which the origin is unknown. IST is characterised by the muscles which control the
neck locking into sustained involuntary painful contraction. It is a neurological
condition and the symptoms are aggravated by stress (STDystonia, 2012). Study 4
(Agnostini et al, 2010) evaluated attachment style and early parental experiences
and connection with Crohns Disease. This condition is chronic and causes
inflammation of the lining of the digestive system, most commonly in the small or
large intestine. The cause is unknown, but possible explanations include genetics
and dysregulation of the immune system causing inflammation (NHS Choices,
2015). Study 5 (Ercolani et al, 2004) evaluates the association between attachment
styles, parental bonding and discomfort in Gastroesophageal Reflux Disease
(GERD) patients. This is a chronic disorder where digestive enzymes and acid flow
backwards from the stomach into the oesophagus (the tube carrying the food from
the mouth to the stomach) due to weakness in the lower oesophageal sphincter. This
acidity causes symptoms from heartburn to permanent damage to the oesophagus
(Community Connect to research, 2015)

5.5: DATA EXTRACTION

52
A standardised form for data extraction was developed, with reference to the
inclusion/exclusion criteria and PICOT, to ensure the relevant information was
extracted from the studies in order to answer the research question (See Appendix
5-9 for the fully completed forms). A synthesis of all 5 data extraction forms was
performed to allow ease of comparison between studies (See Table 5.9).

TABLE 5.9: S YNTHESIS OF DATA EXTRACTION FORMS

(See Page 52)

Study No. 1.Picardi 2.Puig 3.Scheidt 4.Agnostini 5.Ercolani
Country Italy, Local USA, University Germany, Italy, University Italy, University
and National of Minnisota, Freiburg of Bologna, of Bologna
Setting Health Service Dept of Neurological Dept of Digestive Clinic
Unit Psychology Uni. Hospital Psychology
Inclusion 60 years old, Women in third Cases: IST Cases: CD in 20-70 years old.
Criteria in current job 2 trimester of patients remission Cases: Suffering
years, no pregnancy Controls: Controls: from Gastro-
chronic health (participants are physically physically esophageal
conditions, no first-born healthy. healthy, no Reflux disease
treatment with children of these No steroids, intestinal Controls:
drugs affecting participants pregnancy, disease, All physically
immunity, birth control participants: healthy
psychiatric use, medicat. No steroid or
conditions psychiatric antidepressant
treatment treatment
Sample 65 163 38 408 177
size Caucasian Male: 80 Cases: 19 Cases: 102 Cases: 72
female nurses Female: 83 10 men/10 47 men/55 35 men/37
women women women
Controls: 19 Controls: 306 Controls: 105
10 men/10 142 men/164 55 men/50
women women women
Sampling Random Women in 3rd Cases: Cases: Cases:
sample of trimester of purposive Purposive Purposive
female nurses pregnancy from sample from sample from sample from
from National Midwestern USA hospital unit IBD unit clinic
Health Service city (participants Controls: Controls: Controls:
Unit = first born Convenience Random sample Convenience
children) sample from of general sample from
advert in local population in general
newspaper same area population
Mean Age 36.8 7.4 32 (measured Cases: Cases: Cases:
(24-58) for physical 46.5 10.7 44.53 12.87 45.3 13.5
illness) (36-57) (32-57) (32-59)
Newly born Controls: Controls: Controls:
children 45.8 9.8 42.69 13.71 44.9 5.8
recruited (36-56) (29-56) (39-51)
Blinding Yes Not stated Yes Not stated Yes
ID of con- Yes Yes Yes Yes Yes

53
 founders
ID & Yes Yes Yes Yes Yes
control of
variables
Attachment ECR* SSP* AAI + Q-Sort* ASQ + PBI* ASQ + PBI*
measure
Physical Natural Killer Adult Health Neurological Diagnosis of CD Diagnosis of
health cell (NKCC) + Survey Assessment and CD activity pure GERD and
measure Lymphocyte for IST, Saliva index (CDAI) GERD with
PR Cortisol other pathology
Outcome Association Insecure Associated Insecure Insecure
between attachment insecure attachment attachment
immunity & predicted attachment & associated with associated with
attachment- likelihood of IST and CD; perceived GERD
related adult physical avoidance low maternal
avoidance illness predicts stress care and father
response overprotection
*Full name of each acronym can be seen in Table 12 below

5.5.1: S UMMARY OF EXTRACTED DATA

Of the five studies, three were conducted in Italy, one in Germany and one in USA.
Four were carried out in Universities, two in Psychology Departments and two in
University clinics or hospitals; one study was carried out in a local National Health
Service Unit. The three case-control studies were all matched on age and gender
(amongst other within study matching). The longitudinal study was one year in
duration, whilst the longitudinal cohort study followed participants over thirty years.
The inclusion criteria for four studies required the participants to be in good physical
and psychological health (this requirement was for the controls not the cases in
case-control studies) - the longitudinal cohort study was comprised of new-born
babies, presumed healthy, as no disease was recorded and the study aimed to
predict adult illness. Three studies had larger sample sizes of 163, 177 and 408,
whilst two studies had small sample sizes of 38 and 65. The ages of participants in
all studies were 29-59. The mean age of participants in the case-control groups were
42-46, whilst the mean age of the participants in the other studies was younger:
36.7 in the longitudinal study and 32 in the longitudinal cohort study. The case-
control studies were measuring associations between attachment and specific
diseases or conditions i.e. GERD, Crohns Disease and IST, whilst the two
longitudinal studies were addressing immunity; and the other observing participant
reporting of physical illness, inflammation related illness and nonspecific symptoms.

54
All three case-control studies used purposive sampling from clinics or hospital units
for the cases. One used random probability sampling of the general population in
the same geographic area as controls, and the other two used
convenience/volunteer sampling from either the general population or local
newspaper advert. Of the two longitudinal studies, the cohort study used purposive
sampling from public health clinics (it could possibly have been random sampling but
this is not made clear); the other study used random sampling of female Caucasian
nurses from National Health Service Unit.

Three studies included blinding, whereas in two others, it was not stated. All studies
identified confounders and identified other variables measured and controlled for. All
studies used a verified and reliable attachment measurement tool. Four studies
used valid and reliable disease/condition measurement tools, although the
longitudinal cohort study used a self-report adult health survey questionnaire. All
studies found an association between attachment and the disease or condition
measured (See Appendix, Tables 5-9)

5.5.2: ATTACHMENT MEASUREMENT TOOLS

The tools used within the studies measure attachment over different domains: ECR
measures general attachment (or partner); SSP, AAI and PBI measure attachment
with parents (SSP mainly mother), and ASQ measures attachment and close
relationships. As each measurement tool uses different words for the style of
attachment, Table 5.10 shows these as synthesised to show how these relate to
either anxious or avoidant types of insecure attachment.

Adult attachment self-report questionnaires measure conscious perceptions of how

individuals view themselves at the present time with regards to relationships with
others (Milulincer et al, 2007). AAI interview can expose subconscious triggers
linked to attachment experience and views attachment as stable over time, as does
SSP (Shi et al, 2013). SSP measures attachment in respect to observed infant
behaviour patterns towards the primary caregiver. One criticism of SSP is that it only

55
measures mother-infant bonds. Modern day multicultural measurements should
consider other adults as the primary caregiver i.e. father, grandparent (Dewar, 2014)
A question to be considered when assessing the results of attachment
questionnaires when used alone, rather than with the addition of a
physiological measurement: if an individual is anxious/ambivalent and
their predication is towards seeking greater contact or approval from
others, do they consciously or subconsciously deny this in order to seem
more socially acceptable? Could this skew the questionnaire results?
Similarly, do avoidant individuals attempt to outwardly show themselves
amenable to close relationships, while reacting physiologically in a highly-
stressed manner to intimacy? Gander and Bucheim (2015) posit that
interviews and behavioural observation (as seen in the AAI interview and
SSP - Situation Strange Procedure) provide analysis of unconscious
defensive process, which self-report measures do not. Inclusion of
physiological measures such as skin conductivity, cortisol stress-hormone
measurement and ECG could show emotional and affective responses,
rather than just cognitive, allowing for a mind and body involvement
measure (Diamond et al, 2001). Of the studies in this Review, Study 3 used the
AAI interview and also measured cortisol levels, which incorporates cognitive,
affective/emotional and physiological aspects; study 2 used SSP (Situation strange)
behavioural observation which incorporates subconscious aspects when
categorising attachment; study 1 used longitudinal measures of immune function as
a physiological measure of increased risk for physical illness or disease (Gouin,
2010). Studies 4 and 5 both used two attachment questionnaires which measured
attachment over different domains parents and also close relationships, but did not
use any physiological measurements for unconscious responses.

TABLE 5.10: ATTACHMENT MEASUREMENT TOOLS & TERMS FOR ATTACHMENT

STATUS

Study Attachment Measurement Tool Insecure attachment style Relationship

Focus
1.Picardi Experiences in Close Relationships Anxious/preoccupied Partner or
(2012) (ECR) Avoidant general
Self-report questionnaire
2.Puig Ainsworth Strange Situation Anxious/resistant Mother

56
(2013) (SSP) Avoidant/anxious (primary
Infant behaviour observation caregiver)
3.Scheidt Adult Attachment Interview and Q- Anxious/preoccupied Parents
(2000) Sort (AAI) * Avoidant/dismissing
Adult Interview
4.Agnostini Attachment Style Questionnaire Anxious or Avoidant = Close
(2010) (ASQ) Confidence level relationship
Self-report questionnaire Anxious = s
Need for approval
Anxious =
Preoccupation with relationships
Avoidant = Relationship as
and secondary
Avoidant = Discomfort with
closeness

Parental Bonding Instrument Anxious: Overprotection/high

(PBI) care; Avoidant: Low Parents
Self-report questionnaire overprotection/low care
In general:
High scores on care show
perceived parental warmth and
affection/low scores show
perceived neglect & rejection.
High scores on overprotection
show perceived excessive
control/intrusive parents; low
scores show perceived parental
acceptance of independence in
child
5.Ercolini ASQ and PBI
(2004) Both self-report questionnaires As for study 4. above
*Classification of the original AAI scoring by Q-sort results in the same classification in 80% of cases
(McLeod, 2014; Ravitz et al, 2009)

5.6: DISCUSSION OF OUTCOME STATISTICS FOR INDIVIDUAL STUDIES

The results and statistics from each study are discussed below, with the table of
statistics available in Appendix 10:

5.6.1: S TUDY 1 P ICARDI ET AL (2012)

Using Spearmans Correlation, an expected relationship was found between NKCC

and NKCC cell number (indicating that if NKCC levels were reduced, so were the
NKCC cell numbers) and also between insecure attachment styles anxious and
avoidant. Due to the researchers previous cross-sectional study (Picardi et al, 2007)

57
showing a possible effect between high levels of attachment-related avoidance and
NKCC, they measured for a non-linear association. An association was found
between high levels of avoidant attachment and NKCC , i.e. when avoidance levels
are high, NKCC levels are low, indicating reduced or compromised immunity, -1.87 (-
3.12 0.63), p = 0.003. Multiple regression of NK cell toxicity showed positive
correlation with avoidance-related attachment, -1.71 (-2.90 - -0.51), p = 0.005. The
results point to consistently lower NKCC levels, indicative of compromised immune
system, (measured over one year) in participants with high levels of attachment-
related avoidance.

5.6.2: S TUDY 2 P UIG ET AL (2013)

Binary logistic regression showed that participants classified as anxious/resistant

attached at 18 months old were significantly predicted to be x6 more likely to report
physical illness than securely attached OR 5.92, 95% CI 1.56 19.87, p 0.01. No
significance was found for avoidant-attached individuals. Avoidant-attached
individuals were x3 more likely and anxious/resistant x7.5 more likely than secure
individuals to report inflammation-related disease; avoidant OR 3.32, CI 1.50
14.62, p < 0.05; anxious/resistant OR 7.54, CI 1.68 21.56, p < 0.01. In non-
specific disease reporting, there was no significant difference between insecure and
secure attachment. Individuals who were insecurely attached at both 12 and 18
month times (x2) were approximately x4 more likely, at age 32, to report physical
illness, inflammation-related illness and non-specific illness than those who were
secure at both points in time. A result unrelated to attachment did arise higher BMI
caused individuals to be slightly more likely to report physical illness, inflammation-
related illness and non-specific symptoms, with the results being significantly
significant (although this is not a confounder as it was controlled for in analysis). The
results indicate that infant attachment style may predict the likelihood of experiencing
physical illness in adulthood.

5.6.3: S TUDY 3 - SCHEIDT ET AL (2000)

58
This study found a 75% of patients with Idiopathic Spasmodic Torticollis suffered
from insecure attachment. The small sample size of this study does not allow
significant population inferences to be made from this percentage. The Initial Cortisol
Response (ICR) was measured (taking levels from before, during and after the AAI
interview) and analysed via a 2-way ANOVA. This aimed to compare attachment
style and the levels of cortisol stress response elicited whilst undertaking the AAI
interview. It was hypothesised that the AAI would activate the behavioural system
through psychosocial stress and increase cortisol levels in the insecurely attached
group. A significantly higher level of cortisol was found in the dismissing (avoidant)
IST sufferers. (F = 7.23, p = 0.003). This seems to indicate that avoidant individuals
respond with higher physiological arousal and prolonged stress response which is
detrimental to health, than secure or anxiously attached individuals when under
psychosocial stress.

5.6.4: S TUDY 4 AGNOSTINI ET AL (2010)

The Attachment Style Questionnaire (ASQ) scores indicated that patients with
Crohns Disease (cases) show statistically significantly lower scores on the sub-
scales of confidence (indicating insecure attachment) F = 51.52, p < 0.0001; need for
approval F = 6.12, p < 0.05 and preoccupation with relationships F = 11.81, p < 0.01,
both indicating anxious attachment. The Parental Bonding Instrument scores show
that perceived maternal care and affection was low in Crohns Disease (CD) patients
compared to healthy controls; father overprotection was high indicating excessive
paternal control and lack of childs independence. Interpretation of these scores
should take into account the counterbalance of paternal care and maternal
overprotection being equal in cases and controls. Results show significantly higher
scores on ASQ for anxious attachment in Crohns Disease sufferers, suggesting an
association.

5.6.5: S TUDY 5 E RCOLANI ET AL (2004)

59
Multiple T-Tests were undertaken for the results of the Attachment Style
Questionnaire (ASQ) and Parental Bonding Instrument (PBI). A Bonferroni
adjustment was considered too conservative, so significance level was set at 0.01.
The ASQ showed that scores on the sub-scale of confidence levels were significantly
lower for the whole GERD group and opposed to healthy controls, indicating
insecure attachment, 26.6(5) v 33.4(5), t = 4.96, p < 0.001. Repeated for the sub-
group of pure GERD (approximately 50% of the whole GERD group), a very similar
significance for insecure attachment in the pure GERD group was seen: 29(5.1) v
33.4(5), t = 4.72, p < 0.001. Subscale score (of the ASQ) in discomfort with
closeness in the pure GERD group was significantly lower than the control group
(possibly indicating their ease with depending on others and having no difficulty in
being close to others). The pure GERD group indicated a significantly higher score
on the Parental Bonding Instrument for overprotective mother, which may indicate
excessive perceived maternal control. These score must be interpreted in the
knowledge that there was a protocol deviation, allowing the presence of an
accompanying person in the interview. This could have introduced bias and skewing
into all the results of this study (Bhatt, 2012). A tentative association may be
deduced between GERD and insecure attachment.

5.7: NARRATIVE SYNTHESIS OF RESULTS

The results of this Review address the research question by showing how insecure
attachment contributes to health outcomes in adults. Avoidant attachment is
associated with compromised immunity*, although this result requires further study in
order to generalise to populations beyond Caucasian females. As measured in 18
month old infants and reported at age 32, anxious/resistant attachment is a risk
factor for reporting physical illness and inflammation-related disease, while avoidant
attachment is a risk factor for reporting inflammation-related disease. Insecure
attachment as stable over 2 points in time in infanthood, is a risk factor in reporting
physical illness, inflammation related disease and non-specific conditions (See
Appendix 11 for a description of these illnesses). Avoidant attachment is associated
with a higher stress hormone response** to psychosocial stressors in patients with

60
Idiopathic Torticollis; a neurological condition associated with dysfunction of the
nervous system (Grover, 2015). This result (and the result for Crohns Disease study)
may not be generalizable to the general population due to differences in sampling
cases and controls; the small sample size may have affected estimations of
secure/insecure participants showing symptoms of torticollis. Insecure attachment,
mainly anxious-attachment, shows an association as a potential risk factor for
Crohns Disease, which is an inflammatory condition with links to immune system
dysregulation (NHS Choices, 2015). There is a tentative association between GERD
and insecure attachment, but a more rigorous study would be required to generalise
to the wider population or to make any serious inferences. See Fig 5.2 for insecure
attachment associations with health outcomes.
*Compromised immunity is not considered a clinical endpoint i.e. it does not show
manifestation of disease such as heart attack; it is a surrogate endpoint which can
predict future disease
** Stress hormone response and cortisol levels are considered biological
mediators and are not health outcomes i.e. they do not have critical
clinical relevance (Robles & Kane, 2014)
FIG 5.2: INSECURE ATTACHMENT AND ASSOCIATIONS WITH HEALTH OUTCOMES

INSECURE ATTACHMENT
Reporting physical illness
Reporting inflammation-related illness
Reporting non-specific symptoms

Anxious attachment AVOiDANT attachment

Reporting physical illness
Reporting inflammation-related illness
Risk factor for Crohns disease
Minor association with Gastroesophageal
Reflux Disease (GERD)
Reporting inflammation-related illness
Compromised immunity (low NKCC)
Higher stress-hormone response in
patients with Idiopathic Torticollis

6.0 Discussion

This Review was conducted to answer the question of whether insecure attachment
can contribute to health outcomes in adults and thereby also consider the possible

61
connections between affect, emotion, cognition and stress responses involved with
insecure attachment and the resulting influence on health outcomes.

The systematic search for studies for inclusion in the Review was undertaken only
using electronic databases. Although this was a thorough search, identifying all
studies which met the inclusion criteria, it may not be concluded that the Review was
based on synthesis of all available evidence (See 7.0: Limitations) therefore the
results of the Review must be viewed in this context. Eight studies were identified
from strict inclusion criteria. At the quality assessment stage, three cross-sectional
studies were excluded in order to only include studies to enable best evidence
synthesis: McWilliams et al (2010) was excluded due to flaws in the use of
measurement tools; Rossi et al (2005) due to non-inclusion of other risk-factors and
methodological issues; Robles et al (2014) due to non-inclusion of response factors.
The research in the five studies included in the Review was undertaken using
different study designs and outcomes measures and were therefore were too
heterogeneous for a meta-analysis of the results, therefore best evidence narrative
synthesis was employed to provide an overview of the synthesis of all the results. A
table of statistics was included for further interpretation.

The results of this Review show associations with insecure attachment (including
sub-categories of anxious and avoidant attachment) and physical illness. In
particular, these associations point to conditions with compromised immunity and/or
inflammation.

The Puig et al (2013) study was longitudinal over 30 years, allowing the direction of
effect to be seen indicating infant insecure attachment as a predicator of adult ill-
health. Large confidence intervals in this study could indicate variable data or small
sample size. The data may be variable due to individual differences in attachment
over time i.e. an individual insecurely attached at infanthood could have experienced
buffering effects of other secure romantic or peer relationships, thereby reducing
sustained stress reactions and lessening the impact on health. Other research
corroborates these findings: it has shown that the foundation for attachment style is
formed in childhood, resulting in variations in affect regulation and stress response

62
which can impact on health outcomes in later life, but possible changes in
attachment style due to support received from other attachment figures across the
lifespan may buffer the effects of stress reactions (Sroufe, 2005)

The case control study by Agnostini et al (2010) on Crohns Disease cannot be

generalised due to sampling differences in cases and controls (as with the Ercolani
et al (2004) study on GERD), therefore only hypotheses can be generated. Also both
studies used self-report attachment measures which can be influenced by present
mood/life stress rather than showing intrinsic long term attachment style. Self-report
measures of attachment at one point in time do not show the direction of the effect
on illness, nor do they measure subconscious representations of attachment. Both
these studies hypothesise that insecure attachment is linked to both Crohns Disease
and GERD, which are both inflammatory conditions of the gastrointestinal system.
An association between insecure attachment and these condition was also explored
by Maunder & Hunters (2001) research where they posit that insecure attachment
could be an extra risk factor for individuals who already have an existing vulnerability
for a specific disease. This Review showed (Picardi et al, 2012) that insecurely
attached Caucasian Women were associated with lower immunity this factor is not
a clinical endpoint, but a surrogate endpoint which can predict future disease.
Research by Everly & Lating (2002) link this surrogate endpoint with an increased
risk of disease: they suggest that potential target organs for stress-response include
the immune system, gastrointestinal system and the cardiovascular system amongst
others. If coping strategies are not successful (i.e. affect/cognitive dysregulation)
then target organ triggers are maintained, increasing risk of disease

The Scheidt et al (2000) study included a small sample size which may not be
representative of the reported percentage of insecurely attached individuals
experiencing torticollis. They used an interview attachment measure (as stress
stimulus) alongside physiological cortisol measurements over several times and
days, which results in a robust measurement of unconscious attachment-related
stress response. However, dysfunctional cortisol response is a biological mediator
and not an indicator of disease causation. Other researchers do link stress response
to ill-health: insecurely attached individuals modulate their emotional response to

63
environmental demands, consciously and subconsciously, via rigid dysfunctional
responses to threats to their attachment system. If sustained over long time periods
of time, this can contribute to allostatic overload where the bodys restorative
processes, involving the body and mind, are compromised resulting in vulnerability
disease and ill-health (McEwen, 2005). Attachment style determines whether a
stimuli is experienced as a stressor or not, although individual differences also affect
this response genetics, personality, learning history and coping mechanisms
(Everly & Lating, 2002).

The pathway from the psychophysiological responses of insecure attachment to ill-

health i.e. the mind/body connection can be interpreted as follows: Heightened
response to perceived stressors in insecure attachment involves either chronic over-
activation or increased reactivity and physiological arousal of the autonomic,
endocrine and immune stress-regulation systems (Diamond et al, 2006). Stress-
related dysfunction of the HPA Axis (neuroendocrine stress-response system) leads
to elevation in glucocorticoids (e.g. Cortisol) which are immune-suppressive. This
can lead to impaired immune system and greater susceptibility to inflammatory and
auto-immune disease (Silverman & Sternberg, 2012). A decrease in NKCC cells are
related to autoimmune diseases (fewer cells limit pathogens the immune system can
defend against) such as Crohns Disease, which is an immune-mediated
inflammatory condition and causes inflammation in the gastrointestinal tract
(Luneson, 2009; Jaremka et al, 2013). Torticollis is a neurological condition and
chronic stress is reputed to impact on neurological conditions by supressing the
immune system and increasing inflammation, although there are many other
explanations for causes of neurological conditions, such as environment, lifestyle,
infection, genetics and physical illness (McEwen & Stellar, 1993). GERD is an
inflammation of the oesophagus and digestive tract and is related to the immune
system causing inflammation; it is also related to genetics (NHS Choices, 2015).
Inflammation-related conditions, such as those identified in Puig et al (2013) study
include angina or heart disease; asthma, bronchitis and emphysema; diabetes,
hypertension and stroke. Inflammation is connected to most chronic diseases
(Marquis, 2013).

64
7.0: Limitations
As the search for studies to be included in the Review was restricted to searching
electronic databases, which mainly consist of published articles, this could introduce
publication bias. This is caused through omitting to include possible selection of
unpublished articles, report, conferences presentations and discussion papers which
are collectively known as grey literature. Other searches for relevant studies could
have been identified through hand-searching references and citations of study
articles. These additional searches were not carried out due to time restrictions, but
it is acknowledged that all relevant literature on the subject addressed by the
research question may not have been identified. Identification of unpublished
articles in the subject area may have shown more recent research, or research with
conflicting views to the published articles used in this Review (Hemingway, 2009)

Only one reviewer screened the studies by title, abstract and full text articles to
identify studies which met the definition and inclusion criteria for the Review.
Subsequently the same reviewer performed quality assessment, extracted and
analysed the data. Usually two researchers would share this responsibility in order to
minimise bias, and enhance reliability and quality assessment, with a third
researcher included to settle disputes (Bettany-Saltikov, 2012). Bias and subjectivity
cannot be completely eliminated if only one reviewer is undertaking these processes,
although transparent reporting at each stage reduces the possibility (EBBP, 2007).
An advisory group would usually be employed for consultation at key stages of the
Review and for advice on the intended audience and dissemination (CRD, 2009)

8.0: Conclusion
From the results of this Review, it can be concluded that insecure
attachment may be a predicator of ill-health in adults, but that individual
differences in secure attachment relationships over time may offer
buffering or protective effects on health. Insecure attachment is
associated with dysfunctional stress responses to attachment system
threats, with avoidant-attached individuals responding with higher
physiological arousal and prolonged stress response than anxious or

65
secure-attached individuals. Although this does not indicate ill-health in
itself, it is hypothesised that if existing vulnerabilities in the immune,
gastrointestinal and nervous systems already exist, insecure attachment
may be an extra risk factor for a compromised immune system
contributing to inflammatory diseases, such as Crohns Disease and
Gastroesophageal Reflux Disease. Another hypothesis may be that the
psychophysiological stress responses of those insecurely attached contribute to
vulnerability in these systems, thereby exposing them to increased risk of disease.

9.0: Recommendations for future research

Further research is needed on individual differences in attachment style: Is the
attachment reactivity pattern is set or can be moderated over time to improve
emotion, affect and physiological regulation; do various degrees of severity of
insecure attachment exist, and what are the implications for health? (Moutsiana et al,
2014) Feeney et al (2000) posit attachment should be viewed, not only as secure or
insecure, but as a multi-dimensional construct of how stressors are perceived, the
resulting stress response, and relationships with attachment figures. This Review
has shown that avoidant-attached individuals show greater physiological response to
attachment system stressors. In current research, many studies only use self-report
questionnaires which measure mainly conscious, cognitive responses. As much of
the process of stress response to attachment system threat is physiological, this
should be measured. Physiological measures, such as skin conductivity or heart
rate should be used as a measurement of unconscious physiological reactions,
across multiple stressor inducing environments to make a distinction between
thoughts, emotions and affect regulation (Diamond, 2001).

66
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Appendices

Appendices

APPENDIX 1: SEARCH STRATEGY STRING

1 Adult
2 Insecure attachment
3 Attachment behavio#r
4 Attachment style
5 2 OR 3 OR 4 (combined terms using OR)
6 Physio*
7 Health-related

84
 8 Illness
9 Immun*
10 6 OR 7 OR 8 OR 9 (combined terms using OR)
11 1 AND 5 AND 10 (combined terms using AND)

APPENDIX 2: KEY SEARCH TERMS FOR BIBLIOGRAPHIC DATABASES

CINAHL, MEDLINE, PsycINFO, PsycARTICLES, Hits Date

Psychology and Behavioural Sciences Collection Run
(EBSCOhost 1957-2015)
S1 insecure attachment OR attachment style OR 3,514 15/07/15
attachment behavio#r
health-related OR physiol* OR illness OR immun*
S2 533,055
adult
S1 AND S2 AND S3
S3 781,604
S4 746
EMBASE
(Ovid SP 2000-2015)
6 Adult 485,6671 13/07/15
(health-related or physiol* or illness or immun*).mp. 501,3491
[mp=title, abstract, heading word, drug trade name,
7 original title, device manufacturer, drug manufacturer,

85
 device trade name, keyword]
(insecure attachment or attachment behavio#r or
attachment style).mp. [mp=title, abstract, heading
word, drug trade name, original title, device
8 manufacturer, drug manufacturer, device trade name, 1,701
keyword]
6 and 7 and 8

9 112
SCOPUS 14/07/15
(1974-2015)
1
History Search TermsTITLE-ABS-KEY ( adult ) 6,399,343

History Search Terms( TITLE-ABS-

2
KEY ( insecure attachment ) OR TITLE-ABS-KEY (
attachment behavio#r ) OR TITLE-ABS-KEY ( atta 4,554
chment style ) )

History Search Terms( TITLE-ABS-

KEY ( physiol* ) OR TITLE-ABS-KEY ( health-
related ) OR TITLE-ABS-KEY ( illness ) AND TITLE
3
-ABS-KEY ( immun* ) )
278,936
History Search Terms( TITLE-ABS-
KEY ( adult ) ) AND ( ( TITLE-ABS-KEY ( insecure
attachment ) OR TITLE-ABS-KEY ( attachment be
havio#r ) OR TITLE-ABS-KEY ( attachment style )
) ) AND ( ( TITLE-ABS-KEY ( physiol* ) OR TITLE-
4 ABS-KEY ( health-related ) OR TITLE-ABS-KEY ( ill
ness ) AND TITLE-ABS-KEY ( immun* ) ) ) 13

APPENDIX 3: STUDIES EXCLUDED AT THE SECOND SELECTION STAGE

Stud Name and Reason for Exclusion

y No. year
1 Gick et al The study was discarded primarily due to the focus being
(2010) related to social support and coping strategies. Possible
response bias as recruited from internet - may report greater
disease severity and symptoms. No diagnosis was
included.
2 Picardi et al The study was discarded due to the focus on exacerbation,

86
 (2005) not onset of condition. Investigation of the role of stressful
events, social support, alexithymia and also attachment
security in the exacerbation of psoriasis.
3 Gouin et al The study was discarded due to lack of evidence of
(2009) measurement instrument to show increased risk of ill-health.
Research to link attachment avoidance to inflammatory
responses to martial conflict. In this study increased IL-6
plasma levels were used as an indicator of inflammatory
response and increased risk of developing cardiovascular
disease and other conditions the study referenced Ridker
et al, 2000. In other research (Steerberg et al, 2000),
increased IL-6 levels have been cited of having a beneficial
role through growth factor abilities. Scheller et al (2011)
state that regenerative/anti-inflammatory properties of IL-6
are mediated by classic signalling and pro-inflammatory
activity of IL-6 is mediated by trans-signalling

7 Barbosa et al The study was discarded due to attachment style being

(2011) examined as the secondary predicator. Prevalence of
alexithymia traits in individuals with the condition was
correlated with attachment style.

10 Caplan et al The study was discarded as the primary purpose was to

(2014) study the relationship between childhood abuse and overall
disease activity, with attachment as a moderator

12 Picardi et al The study was discarded as it is a duplicate of study

(2007) Number 14.

13 Maunder et al The study was discarded due to the primary focus on the
(2005) associations between depression and ulcerative colitis
disease activity.

APPENDIX 4: STUDIES EXCLUDED AT QUALITY ASSESSMENT STAGE

McWilliams et al, 2010 Robles & Kane, 2014 Rossi et al, 2005

How well was the study done to minimise risk of bias?

87
Participants not randomly Sample size required and Participants not randomly
selected not response rates not selected not
representative of discussed representative of
population population
Steps not taken to
Characteristics of non- maximise sample size Characteristics of non-
responders not discussed responders not discussed
Characteristics of non-
Assessment one tool not responders not discussed No confidence intervals
valid No confidence intervals
Other confounding
No training mentioned for variables influencing
staff conducting interviews disease severity were not
Measurement tool not considered
reliable

APPENDIX 5: DATA EXTRACTION FORM

Study 1

88
Bibliographic details of study Picardi, A., Miglio, R., Tarsitani, L., Battisti, F., Baldassari, M.,
Copertaro, A. Mocchegiani, E, Cascavilla, I. & Biondi, M. (2013)
Attachment style and immunity: A 1-year longitudinal
study, Biological psychology, 92(2), pp. 353-358
Date of extraction 3rd August 2015
Purpose of Study To establish the reliability of the association between
attachment-related avoidance and immunity
Study setting Ancona, Italy
Local National Health Service Unit
Study design Longitudinal study
Inclusion/exclusion criteria <60 years old, in current job for 2 years, absence of infectious
diseases and chronic medical conditions, no history of major
psychiatric disorders and no current treatment with drugs
affecting the immune system
Population Sample size: 65.
Caucasian female nurses.
Mean age 36.8 7.4 years (24-58)
Sample and recruitment Random (probability) sample recruited from National Health
Service Unit
Response rate 100% (Study was incorporated into periodic occupational health
examinations)
Blinding Immune assays were performed blinded to all other measures
collected
Identification of confounders Males were excluded, due to small number of male staff and
possibility of confounding effect of gender
Other Variables measured and Alexithymia scale TAS-20) difficulty identifying feelings,
controlled for Percieved Stress Scale (PSS), Scale of Perceived Support
(MSPSS), alcohol, tobacco, NSAIDS (pills per week), sleep,
exercise
Measurement tool for Experiences in Close Relationships (ECR)
attachment Measured at baseline
Measurement tool for Natural killer cell cytotoxicity (NKCC) and Lymphocyte
disease/illness or increased risk proliferative response (LPR) immunity measurements
for ill-health Measured at baseline, 4, 8 and 12 months follow up
Ethics Informal authorization by local Ethical Committee
Results High attachment-related avoidance was found to be
independently associated with lower NKCC levels and
corroborate the link between attachment and altered immune
function.

APPENDIX 6: DATA EXTRACTION FORM

89
Study 2
Bibliographic details of study Puig, J., Englund, M. M., Simpson, J. A. & Collins, W. A. (2013)
Predicting adult physical illness from infant attachment: A
prospective longitudinal study, Health psychology, 32(4), pp.
409
Date of Extraction 3rd August 2015
Purpose of study To prospectively examine the links between the quality of
attachment during the first 2 years of life and various health
problems in adulthood
Study setting University of Minnesota, USA
Department of Psychology
Study design Prospective longitudinal cohort study
Inclusion/Exclusion criteria As for sample and recruitment
Population Sample size: 163
Male 80 (49.1%)
Female 83 (50.9%)
Sample and recruitment Sample frame included low-income sample of women receiving
free health care from public health clinics in a Midwestern USA
city between 1975 and 1977 in their 3rd trimester of pregnancy.
Participants are the first-born children of these participants.
Response rate Not stated
Blinding No blinding mentioned, although consent was sought at each
assessment
Identification of confounders Gender, negative emotional style, body mass index (BMI) and
life stress, Socio-economic status (SES), perceived instrumental
and emotional support
Other variables measured and Martial status, education, employment, household income,
controlled for mothers age at participants birth
Measurement tool for Ainsworth Strange Situation Procedure (SSP)
attachment Measured at 12 and 18 months old
Measurement tool for Adult Health Survey (self-report questionnaire)
disease/illness or increased risk Adapted from the Adolescent Health Survey to be more
for ill-health appropriate for adults
Ethics Ethical approval not mentioned
Consent to participate provided by participants mothers when
they were infants, participants gave their consent for each
assessment from age 13.
Results The quality of parent-child attachment relationships during
infancy predicted the likelihood of experiencing physical
illnesses in adulthood (controlling for several well-known
predicators of physical health).
A sample of 212 participants were assessed at 12 months of age, 197 were assessed at 18
months and 163 assessed and included in this study at 32 years of age. Reasons for attrition were
loss of contact with participant, moving out of state and declining to participate

90
APPENDIX 7: DATA EXTRACTION FORM

Study 3
Bibliographic details of study Scheidt, C. E., Waller, E., Malchow, H., Ehlert, U., Becker-Stoll,
F., Schulte-Mnting, J. & Lcking, C. H. (2000) Attachment
representation and cortisol response to the adult attachment
interview in idiopathic spasmodic torticollis, Psychotherapy and
psychosomatics, 69(3), pp. 155-162.
Date of extraction 3rd August 2015
Purpose of Study Investigation of individual differences in the mental
representation of attachment and their impact on the cortisol
response to psychosocial stress in idiopathic spasmodic
torticollis (IST)
Study setting Freiburg, Germany
Freiburg Neurological University Hospital
Study design Case-Control (matched on age and gender)
Inclusion/Exclusion criteria Inclusion Criteria:
Cases: IST patients
Controls: Physically healthy
Exclusion criteria:
Treatment with steroids, endocrinological disease, pregnancy,
current use of contraceptives and current psychiatric treatment
Population Sample size:
Cases: 19
10 men/10 women
Mean age 46.5 10.7 (36-57)
Controls: 19
10 men/10 women
Mean age 45.8 9.8 (36-56)
(Total sample included 40 but saliva sampling was insufficient in
1 subject in each group)
Sample and recruitment Cases
Purposive sample from hospital unit
Controls:
Convenience sample from advertisement in local newspaper
Response rate 100%
Blinding Not mentioned
Identification of confounders Experiments conducted between 12am and 2pm in order to
minimise effects of the time of day on cortisol response
Other variables measured and SCL-90R screening instrument to measure psychological
controlled for variables (anxiety and depression) as covariates of cortisol
response, Toronto Alexithymia Scale (TAS-20) to study difficulty
in experiencing and expressing emotions, as covariate of
physiological response
Measurement tool for Adult Attachment Interview (AAI) Q-sort (also served as
attachment stimulus of the adrenocortical stress response)
Measurement tool for Neurological assessment: Standardised IST form to measure
disease/illness or increased risk postural abnormality of head.
for ill-health Saliva cortisol measure as biological marker of cortisol
responsemeasured 30 min before interview, beginning of
interview, 3 samples in time intervals of 10 min after termination

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 of interview. Two reference samples also collected on another
day (8am and 12pm) to determine cortisol level at the time of
interview independently of the test situation
Ethics No ethics mentioned
Outcome Insecure attachment is more prevalent in IST than the non-
clinical group, with dismissing attachment predicting cortisol
stress response to the AAI
APPENDIX 8: DATA EXTRACTION FORM

Study 4
Bibliographic details of study Agostini, A., Rizzello, F., Ravegnani, G., Gionchetti, P.,
Tambasco, R., Straforini, G., Ercolani, M. & Campieri, M. (2010)
Adult attachment and early parental experiences in patients
with Crohns disease, Psychosomatics, 51(3), pp. 208-215
Date of Extraction 3rd August 2015
Purpose of study To evaluate attachment style and early parental experiences in
patients with Crohns Disease (CD) as compared with healthy
people
Study setting University of Bologna, Italy
Department of Psychology
Study design Case-Control (matched on age, gender, education and marital
status)
Inclusion/Exclusion criteria Inclusion criteria:
Cases:
CD in clinical remission as evaluated by CDAI < 150
Controls:
Physically healthy subjects with absence of acute or chronic
illness, intestinal diseases and receiving drug treatment
Exclusion criteria: Active disease, current steroid treatment and
use of antidepressant drugs
Population Sample size:
Cases: 102
47 men/55 women
Mean age: 44.53 12.87 (32-57)
Controls: 306
142 men/164 women
Mean age 42.69 13.71 (29-56)
Sample and recruitment Cases:
Purposive sample from IBD Unit
Controls:
Random (probability) sample from general population in the
same geographic area as case group
Response rate Cases: 90% response rate
Controls: 443 interviewed
Blinding No blinding mentioned
Identification of confounders Medical questionnaire to identify controls as separate from
cases
Other variables measured and Education, marital status
controlled for
Measurement tool for Attachment Style Questionnaire (ASQ) and Parental Bonding
attachment Instrument (PBI)
Measurement tool for Diagnosis of CD and evaluation of CD activity index (CDAI) by
disease/illness or increased risk physicians of the IBD Unit of S. Orsola Malpighi Hospital in
for ill-health Bologna (diagnosis based on endoscopic, histological and

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 radiological findings.
Ethics The study was granted ethical approval by the local ethics
committee
Outcome Patients with Crohns Disease exhibit a predominantly insecure
attachment and perceived parental behaviour as low maternal
care and paternal overprotection
Cases: 142 cases asked to participate, 128 accepted and completed the questionnaire, 26 did not
meet inclusion criteria (Eventual sample size = 102)
Controls: 443 subjects interviewed, 92 excluded as did not meet inclusion criteria, 351
completed the questionnaire, data from 16 was discarded due to missing answers. From the
remaining 335, 306 were selected as matching the cases (Eventual sample size = 306)
APPENDIX 9: DATA EXTRACTION FORM

Study 5
Bibliographic details of study Ercolani, M., Farinelli, M., Trombini, E., & Bortolotti, M. (2004)
Gastrooesophageal reflux disease: Attachment style and
parental bonding 1, Perceptual and motor skills, 99(1), pp. 211-
222
Date of extraction 3rd August 2015
Purpose of Study To evaluate attachment styles, parental bonding and
psychological characteristics and discomfort of
Gastroesophageal Reflex Disease (GERD) patients
Study setting Bologna, Italy
Laboratory of Digestive Motility of the Medical Clinic I at S.
Orsola-Malphighi Polyclinic of University of Bologna
April 2000 March 2001
Study design Case-Control (incident and cases matched on gender,
education, age and marital status)
Inclusion/Exclusion criteria Inclusion criteria : 20-70 years old
Cases: Suffering from Gastroesophageal Reflux Disease
Controls: Physically healthy
Population Sample size:
Cases: 72
35 men/37 women
Mean age 45.3 13.5 (32-59)
Controls: 105
55 men/50 women
Mean age 44.9 5.8 (39-51)
Sample and recruitment Cases
Purposive sample from clinic
Controls:
Convenience sample from general population
Response rate Cases: 80% (20% declined due to time constraints)
Controls: No mention of response rate
Blinding The psychological evaluation was performed blind to clinical
diagnosis
Identification of confounders Interview measured psychopathological comorbidity (DSM-IV
criteria) and no evidence was found for cases or controls
Other variables measured and Marital status, education
controlled for
Measurement tool for Attachment Style Questionnaire (ASQ) and Parental Bonding
attachment Instrument (PBI)

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Measurement tool for Specialist diagnosis (24-hour H-metry, oesophageal manometry,
disease/illness or increased risk gastroduodenal manometry
for ill-health Two distinct situations for diagnosis:
Pure GERD (biliary reflux, esophagitis, laryngitis and chest
pain)
GERD accompanied by other physical pathologies mainly
Intestinal Bowel Disease, Chronic Dyspepsia, Biliary Stones
Ethics No ethics mentioned
Results The results indicate insecure attachment in the clinical (GERD)
group

APPENDIX 10: TABLE OF RESULTS STATISTICS

Study Attachmen Physical Condition Mean CI P value

Numbe t Style
r
1 Avoidant Compromised immunity -1.71 -2.90 - -0.51 p=0.005
NK cell toxicity
Avoidant NK Cell toxicity (non- -1.87 -3.12 0.63 p=0.003
linear)
5*** Insecure GERD 26.6(5) v 4.96(5) p<0.001
T = 4.96
Insecure Pure GERD 29(5.1) v 33.4(5) p<0.001
T = 4.72
*** Caution with interpreting this result as there was a protocol deviation, allowing the presence of an
accompanying person in the interview. This could have introduced bias and skewing into all the
results of this study

Study Attachmen Physical Condition Odds Ratio CI P value

Numbe t Style
r
2 Anxious / Reporting physical 5.92 1.56 19.87 p<0.01
resistant illness*
Avoidant Reporting inflammation- 3.32 1.50 14.62 p<0.05
related disease*
Anxious / Reporting inflammation- 7.54 1.63 21.56 p<0.01
resistant related disease*
Insecure Physical illness ** 2.04 1.21 3.23 p<0.01
attachment
Insecure Inflammation-related 2.32 1.41 4.56 p<0.01
attachment disease**
Insecure Non-specific 1.72 1.01 2.86 p<0.01
attachment conditions**
Study 2:
* These results relate to attachment style at 18 months and physical health measured at age 32
** These results relate to attachment measured as stable over two infant ages 12 months and 18
months (therefore Odds Ratios can be interpreted as x2 the figure shown) and physical health
measured at age 32

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Study Attachmen Physical Condition F Value P Value
Numbe t Style
r
3 Avoidant High sustained cortisol F = 7.23 p=0.003
stress hormone
response to
psychosocial stress
situation in Idiopathic
Spasmodic Torticollis
4 Insecure Crohns Disease F = 51.52 p<0.0001
attachment
F = 6.12 p<0.05
Anxious F = 11.81 p<0.01
Anxious
Study 4:
ASQ sub-scale measurement of low confidence
ASQ sub-scale measurement of need for approval and preoccupation with relationships respectively

Study 2:
A measured control BMI showed small but significant results in the likelihood of reporting physical
illness and inflammation-related diseases, with Odds Ratio of approximately 1.13 and p value <0.01

APPENDIX 11: DESCRIPTION OF ILLNESS AND DISEASE TERMS

Physical health conditions

Angina or coronary heart disease Inflammation
Asthma, bronchitis, emphysema Inflammation
Diabetes or high blood sugar Inflammation
Dizzy spells or fainting spells NSS
High blood pressure or hypertension Inflammation
Migraine headaches NSS
Persistent skin troubles NSS
Chest pains NSS
Recurring stomach trouble, indigestion, diarrhoea NSS
Sciatica, lumbago or recurring backache NSS
Stroke Inflammation

*NSS = Non specific symptoms

(Puig et al, 2013)

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