Attachment and Eating Disorders

The Centre for Eating Disorders Research is at the forefront of research on attachment processes in eating disorders. Our research has focused on attachment insecurity as a predictor of treatment outcomes, and of treatment drop out. Further we demonstrated that attachment insecurity is also a significant predictor of eating disorders symptoms above and beyond variance accounted for by diagnosis alone. A recent paper of ours indicates that attachment avoidance and anxiety are associated with different modes of affect regulation, and that maladaptive affect regulation explains how attachment insecurity is associated with severity of eating disorder symptoms. Below is a list of publications from our Centre on our Attachment and Eating Disorders research theme.

Illing, V., Tasca, G., Balfour, L., & Bissada, H. (2011). Attachment dimensions and group climate growth in a sample of women seeking treatment for an eating disorder. Psychiatry: Interpersonal and Biological Processes, 74, 237-251.

Abstract: Adult attachment and group process research are emerging areas of research for treating eating disorders. In this study, we examined several aspects of group processes: the weekly growth of group therapy climate, the relationship between group climate growth and outcomes, and the impact of group on individual experiences of group climate. Further, we assessed the relationship between adult attachment dimensions and these group processes. Women (n = 264) diagnosed with an eating disorder completed attachments scales pre-treatment, eating disorder symptom scales pre- and post-treatment, and group climate scales weekly during treatment. Treatment consisted of a specialized eating disorders group-based day hospital program with rolling admissions. Engaged group climate increased and Avoidance group climate decreased across weeks of treatment. Engaged group climate growth was associated with improved eating disorder symptoms post-treatment. Higher attachment avoidance at pre-treatment was related to lower Engaged group climate at week 1, and was related to a greater impact of the group on the individual's experience of group engagement. Clinicians might improve group processes and outcomes by tailoring interventions to individuals' attachment avoidance when treating women for eating disorders.
Tasca, G. A., Ritchie, K., & Balfour, L. (2011). Practice review: Implications of attachment theory and research for the assessment and treatment of eating disorders. Psychotherapy. Published online, March, 2011

Abstract: In this paper, we review the research literature on attachment and eating disorders and suggest a framework for assessing and treating attachment functioning in patients with an eating disorder. Treatment outcomes for individuals with eating disorders tend to be moderate. Those with attachment associated insecurities are likely to be the least to benefit from current symptom-focused therapies. We describe the common attachment categories (secure, avoidant, anxious), and then describe domains of attachment functioning within each category: affect regulation, interpersonal style, coherence of mind, and reflective functioning. We also note the impact of disorganized mental states related to loss or trauma. Assessing these domains of attachment functioning can guide focused interventions in the psychotherapy of eating disorders. Case examples are presented to illustrate assessment, case formulation, and group psychotherapy of eating disorders that are informed by attachment theory. Tailoring treatments to improve attachment functioning for patients with an eating disorder will likely result in better outcomes for those suffering from these particularly burdensome disorders.
Demidenko, N., Tasca, G. A., Kennedy, N., & Bissada, H. (2010). The mediating role of self-concept in the relationship between attachment insecurity and identity differentiation among women with an eating disorder. Journal of Social and Clinical Psychology, 29, 1132-1153

Abstract: The purpose of this study was to test structural relationships among developmentally- based factors, such as attachment anxiety and avoidance, and self-concept, which may lead to varying levels of identity differentiation among eating disordered women. We tested a model in which self-concept mediates the relationship between attachment insecurity and differentiation of self among eating disordered women. The sample consisted of 330 women with eating disorders who were referred to an eating disorders treatment program for assessment. Individuals completed self-report questionnaires at intake. Results indicated that higher attachment avoidance was associated with lower identity differentiation indirectly through poorer self-concept. In addition, higher attachment anxiety was directly related to lower differentiation of self, and higher attachment anxiety was also indirectly associated with lower identity differentiation through poorer self-concept. Results are consistent with a developmentally-based theory that suggests attachment dimensions rooted in early family experiences have an impact upon the quality of one's self-concept, which in turn directly impacts on one's identity. Targeting attachment avoidance or anxiety when treating women with eating disorders may result in improved self concepts and more differentiated identities.
Illing, V., Tasca, G. A., Balfour, L., & Bissada, H. (2010). Attachment insecurity predicts eating disorder symptoms and treatment outcomes in a clinical sample of women. Journal of Nervous and Mental Disease, 198, 653-659

Abstract: We examined the extent to which attachment insecurity was related to eating disorder (ED) symptoms, and predictive of treatment outcomes. Women diagnosed with anorexia nervosa (AN) restricting subtype (ANR), AN binge purge subtype (ANB), or bulimia nervosa (BN) completed an attachment scale pretreatment, and ED symptom scales pretreatment (n = 243) and post-treatment (n = 157). A comparison sample of 126 non-ED women completed attachment scales on 1 occasion. Those with EDs had significantly higher attachment insecurity than non-ED. ANB was associated with higher attachment avoidance compared with ANR and BN, and higher attachment anxiety compared with BN. Higher attachment anxiety was significantly related to greater ED symptom severity and poorer treatment outcome across all EDs even after controlling for ED diagnosis. Attachment dimensions substantially contribute to our understanding of ED symptoms and treatment outcome. Addressing attachment insecurity when treating those with EDs may improve treatment outcomes.
Tasca, G.A., Szadkowski, L., Illing, V., Trinneer, A., Grenon, R., Demidenko, N., Krysanski, V., Balfour, L., & Bissada, H. (2009). Adult attachment, depression, and eating disorder symptoms: The mediating role of affect regulation strategies. Personality and Individual Differences, 47, 662-667.

Article Title: Adult attachment, depression, and eating disorder symptoms: The mediating role of affect regulation strategies
Authors: Tasca GA;Szadkowski L;Illing V;Trinneer A;Grenon R;Demidenko N;Krysanski V;Balfour L;Bissada H;
Journal: Personality and Individual Differences Volume 47, Issue 6
Date of Publication: 2009
Abstract: The study examined the role of affect regulation strategies in mediating the relationship between attachment dimensions and both depressive and eating disorder (ED) symptoms. Participants were 310 women seeking treatment for an ED. Structural equation modeling indicated that attachment anxiety contributed to both depressive symptoms and ED symptoms through emotional reactivity. In contrast, only the association between attachment avoidance and depressive symptoms was mediated by emotional deactivation; whereas attachment avoidance had a direct relationship with ED symptoms not mediated by emotional deactivation. The results suggest tailored clinical interventions that take into account attachment style and accompanying affect regulation strategies. Treatment of patients who experience attachment anxiety may emphasize impulse regulation, whereas treatment of ED patients with attachment avoidance could focus on gradual exposure to affective expression. Â© 2009 Elsevier Ltd. All rights reserved.
Tasca, G.A., Balfour, L., Ritchie, K., & Bissada, H. (2007). Change in attachment anxiety is associated with improved depression among women with Binge Eating Disorder. Psychotherapy, 44, 423-433.

Article Title: Change In Attachment Anxiety Is Associated With Improved Depression Among Women With Binge Eating Disorder
Authors: Tasca G;Balfour L;Ritchie K;Bissada H;
Journal: Psychotherapy Volume 44 , Issue 4
Date of Publication: 2007
Abstract: The study examined if the relationship between change in attachment insecurity and target symptom outcomes was moderated by treatment type. Women (N = 66) with binge eating disorder (BED) were randomly assigned to two treatment types: group cognitive-behavioral therapy (GCBT) or group psychodynamic-interpersonal psychotherapy (GPIP). Results indicated significant positive pre- to posttreatment changes in all attachment insecurity scales, but no difference between GCBT and GPIP on these changes. Change in attachment anxiety was related to improved depression for women completing GPIP, but not for women completing GCBT. This indicated a moderating effect of treatment type in explaining the relationship between change in attachment anxiety and improved depression. Changes in attachment anxiety may be important for symptom outcomes related to psychodynamic-interpersonal therapies. -® 2007 American Psychological Association.
Tasca, G.A., Balfour, L., Ritchie, K., & Bissada, H. (2007). The relationship between attachment scales and group therapy alliance growth differs by treatment type for women with Binge Eating Disorder. Group Dynamics: Theory, Research and Practice, 11, 1-14.

Article Title: The relationship between attachment scales and group therapy alliance growth differs by treatment type for women with binge-eating disorder
Authors: Tasca GA;Balfour L;Ritchie K;Bissada H;
Journal: Group Dynamics Volume 11 , Issue 1
Date of Publication: 2007
Abstract: The impact of the treatment context in influencing the relationship between attachment anxiety/avoidance and group therapy alliance growth was examined. Sixty-five women treatment completers with binge-eating disorder received 16 sessions of group cognitive behavioral therapy (GCBT) or group psychodynamic interpersonal psychotherapy (GPIP). Attachment scales were completed before treatment, and a group therapy alliance measure was completed after each therapy session. Growth curve modeling indicated an increasing linear growth in group therapy alliance for both treatments. For GPIP, higher attachment anxiety and lower attachment avoidance were each associated with alliance growth. These relationships were not evident for GCBT. The context of therapy likely activated (in the case of GPIP) or did not activate (in the case of GCBT) defensive attachment strategies. -® 2007 APA, all rights reserved.
Tasca, G.A., Ritchie, K., Conrad, G., Balfour, L., Gayton, J., Daigle, V., & Bissada, H. (2006). Attachment scales predict outcome in a randomized controlled trial of two group therapies for Binge Eating Disorder: An aptitude by treatment interaction. Psychotherapy Research, 16, 106-121.

Article Title: Attachment scales predict outcome in a randomized controlled trial of two group therapies for binge eating disorder: An aptitude by treatment interaction. [References]
Authors: Tasca GA;Ritchie K;Conrad G;Balfour L;Gayton J;Lybanon V;Bissada H;
Journal: Psychotherapy Research Volume 16 , Issue 1
Date of Publication: 2006
Abstract: Patients (N =135) with binge eating disorder (BED) were randomized to a control condition or to one of two 16-session group treatments: group cognitive-behavioral therapy (GCBT) or group psychodynamic interpersonal psychotherapy (GPIP). The two treatments performed equally well, and each resulted in reduced days binged compared with the wait-list control condition. Twelve-month follow-up indicated that improvements were maintained in days binged and in other outcome variables. For women who completed GPIP, higher attachment anxiety was related to improvements in days binged by posttreatment. On the other hand, for women who completed GCBT, lower attachment anxiety was associated with improvements in days binged by posttreatment. Higher attachment avoidance was related to dropping out of GCBT. Although both GPIP and GCBT reduced binge eating, the results indicated that individual outcomes differ across treatments based on level of attachment anxiety and avoidance. (PsycINFO Database Record (c) 2006 APA, all rights reserved) (journal abstract).
Tasca, G.A., Kowal, J., Balfour, L., Ritchie, K., Virley, B., & Bissada, H., (2006). An attachment insecurity model of negative affect among women seeking treatment for an eating disorder. Eating Behaviors, 7, 252-257.

Article Title: An attachment insecurity model of negative affect among women seeking treatment for an eating disorder
Authors: Tasca GA; Kowal J; Balfour L; Ritchie K; Virley B; Bissada H;
Journal: Eating Behaviors Volume 7 , Issue 3
Date of Publication: 2006 Aug
Abstract: The purpose of this study was to propose and test a model of attachment insecurity in a clinical sample of 268 eating disordered women. Structural relationships among attachment insecurity, BMI, perceived pressure to diet, body dissatisfaction, restrained eating, and negative affect were assessed. A heterogeneous sample of treatment seeking women with a diagnosed eating disorder completed psychometric tests prior to receiving treatment. The data were analysed using structural equation modeling. Fit indices indicated that the hypothesized model fit adequately to the data. Although cross-sectional in nature, the data suggested that attachment insecurity may lead to negative affect. As well, attachment insecurity may lead to body dissatisfaction, which in turn may lead to restrained eating among women with eating disorders. Attachment insecurity could be a possible vulnerability factor for the development of eating disorder symptoms among women.
Tasca, G.A., Taylor, D., Bissada, H., Ritchie, K., & Balfour, L. (2004). Attachment predicts treatment completion in an eating disorders partial hospital program among women with Anorexia Nervosa. Journal of Personality Assessment, 83, 201-212.

Article Title: Attachment predicts treatment completion in an eating disorders partial hospital program among women with anorexia nervosa
Authors: Tasca GA; Taylor D; Ritchie K; Balfour L;
Journal: Journal of Personality Assessment Volume 83, Issue 3
Date of Publication: 2004 Dec
Abstract: The goal of this study was to examine if attachment theory can provide a framework for understanding treatment completion in an eating disorders partial hospital program among women with anorexia nervosa (AN). Attachment was measured using the Attachment Styles Questionnaire (Feeney, Noller, & Hanrahan, 1994). As hypothesized, self-reports of high avoidant attachment predicted noncompletion of treatment for those with AN binge-purge subtype (ANB). However, this relationship did not emerge for those with AN restricting subtype (ANR). Also as hypothesized, self-reports of high anxious attachment predicted completing treatment for those with ANB but not for those with ANR. For completers with ANB and ANR, the program was helpful in increasing body weight and lowering drive for thinness, body dissatisfaction, interpersonal problems, and depression. Attachment avoidance, characterized by devaluing one's need for relationships, may be a contraindication for group-based partial hospital treatment of ANB. Attachment anxiety, characterized by high preoccupation with relationships, may facilitate remaining in treatment for those with ANB.
Mikail, S.F., Henderson, P., & Tasca, G.A. (1994). An interpersonal model of chronic pain: An application of attachment theory. Clinical Psychology Review, 14, 1-16.

Title: An interpersonally based model of chronic pain: An application of attachment theory.
Authors: Mikail, Samuel F.; Henderson, Peter R.; Tasca, Giorgio A.
Journal Title: Clinical Psychology Review. Vol 14(1), 1994, 1-16.
Date of Publication: 1994
Abstract: Examines the applicability of attachment theory (ATH) to the development of and adaptation to chronic pain (CP). An overview of traditional psychological models of CP, including psychoanalysis, behaviorism, and cognitive-behavioral (CB) theory is presented. It is noted that psychoanalytic writings on CP are few. The behavioral tradition was more interpersonally based, with its emphasis on social reinforcement of pain behavior. The CB perspective signaled a return to an emphasis on intrapsychic factors in the etiology and maintenance of CP syndrome. The interpersonal dimensions of the pain experience suggested by these theories is discussed. This is followed by a review of J. Bowlby's (e.g., 1981) ATH. The tenets of ATH are used as a foundation for understanding the development of and adjustment to CP, within an interpersonal framework. The 4 attachment groups identified by K. Bartholomew and L. M. Horowitz (see record 1991-33075-001) are described. (PsycINFO Database Record (c) 2009 APA, all rights reserved).