attachment and health attachment and health attachment and health is psychological model which considers how attachment theory pertains to people's preferences and expectations for the proximity of others when faced with stress, threat, danger or pain. in 1982 the american psychiatrist, lawrence kolb, noticed that patients with chronic pain displayed behaviours with their healthcare providers akin to what children might display with an attachment figure, thus marking one of the first applications of attachment theory to physical health. development of adult attachment theory and adult attachment measures in the 1990s provided researchers with the means to apply attachment theory to health in a more systematic way. since that time, it has been used to understand variation in stress response, health outcomes and health behaviour. ultimately, the application of attachment theory to health care may enable health care practitioners to provide more personalized medicine by creating a deeper understanding of patient distress and allowing clinicians to better meet their needs and expectations. history of attachment theory infant attachment john bowlby and mary ainsworth developed attachment theory in the 1960s while investigating the effects of maternal separation on infant development. the development of the strange situation task in 1965 by ainsworth and wittig allowed researchers to systematically investigate the attachment system operating between children and their parents. the strange situation involves separating infant-parent dyads and observing infant behaviours upon reunion. infant behaviour tended to follow patterns, leading to the development of three attachment categories: secure, anxious-avoidant, and anxious-resistant. in 1990, ainsworth added a new category, championed by mary main, called disorganized/disoriented attachment, characterized by its less reliable pattern of behaviour. bowlby believed attachment to be a primary biological drive to achieve proximity with a caregiver that transforms across child development to also encompass a psychological drive to find security by achieving a preferred interpersonal distance with an important caregiver he called an attachment figure. insecure attachment patterns develop when caregivers are experienced as inconsistent or unpredictable, which necessitates the development of different strategies to achieve a sense of comfort and safety within an interpersonal setting. furthermore, he posited that attachment figures function as a secure base that facilitate environmental eexploration and that attachment behaviours are triggered by perceived stress, danger or pain, and are thus state dependent. adult attachment in the late 1980s cindy hazan and phillip shaver applied attachment theory to adult romantic relationships based on observations of the interactions between adult romantic partners.☃☃ they noticed that romantic partners often prefer to be physically close, become anxious when they are separated and that stressful situations can be buffered by the presence of a romantic partner. three main methods of measuring adult attachment have been developed, with slightly different purposes and variable amounts of concordance between them. some aim to categorize attachment style while others rate degrees of attachment anxiety and avoidance. attachment styles attachment styles refer to characteristic patterns of thought concerning the ability of self and others to help an individual achieve security. longitudinal studies have suggested attachment is fairly stable from childhood to adulthood. when shifts do occur, it is usually with good reason, it shifts away from secure attachment due to increased hardship and shifts towards secure related to finding partners in adulthood or finding symbolic attachments (god, places, pets, etc.). secure securely attached people generally have positive views about themselves and about others. they tend to agree with statements "it is relatively easy for me to become emotionally close to others. i am comfortable depending on others and having others depend on me. i don't worry about being alone or others not accepting me." insecure anxious-preoccupied people tend to view themselves less positively than they view others. they are more likely to become highly anxious when they are away from their attachment partners and are at risk of becoming, or seeming, dependent. they tend to agree with statements such as "i want to be completely emotionally intimate with others, but i often find that others are reluctant to get as close as i would like", and "i am uncomfortable being without close relationships, but i sometimes worry that others don't value me as much as i value them." avoidant-dismissive people tend to have a positive view of themselves and a less positive view of others. they often highly value independence and become uncomfortable in, or resist, situations where they become dependent on others. they tend to agree with statements such as "i am comfortable without close emotional relationships", "it is very important to me to feel independent and self-sufficient", and "i prefer not to depend on others or have others depend on me." this is considered to be roughly equivalent to the anxious-avoidant style in children. fearful-avoidant people tend to have conflicted, and often negative, views of themselves and of others. they often desire to have emotional relationships but feel uncomfortable when others get too close. they tend to agree with statements such as "i am somewhat uncomfortable getting close to others. i want emotionally close relationships, but i find it difficult to trust others completely, or to depend on them. i sometimes worry that i will be hurt if i allow myself to become too close to others." people with loss or trauma in childhood are at greater risk of developing this style of attachment. insecure attachment styles in healthcare settings anxious-preoccupied people with anxious-preoccupied attachment tend to be hypervigilant to signs of danger and worry or catastrophize about symptoms. in health care appointments, their narrative is full of intense negative emotion but is relatively sparse in the specific detail desired by health care providers. this presentation can readily be perceived as "needy" or "dramatic". if the healthcare provider pulls away in response it may reinforce the patient's need to articulate their distress, creating a cycle of distress-withdrawal-distress. avoidant-dismissive people with avoidant dismissive attachment emphasize their independence and minimizing expressing distress. they may delay seeking healthcare (see healthcare utilization), minimize reporting symptoms and disclose limited personal information. fearful-disorganized people with fearful attachment often avoid routine healthcare, but present in a crisis with volatile, intense, negative emotions. due to their degree of distress, they can present a disorganized narrative that is difficult for providers to follow and interpret diagnostically. working model working models are representatives of the cognitive schema, or psychological structure (often unconscious), which underlie the different attachment classifications. working models develop in children over time based on their experiences with their attachment figures. the cognitive schema for attachment consists of views of the efficacy of self and other to create security in times of distress. bartholomew and horowitz model bartholomew and horowitz proposed and verified a working model based on two dimensions; the view of the self (self-esteem) and the view of others (sociability) secure- positive view of self, positive view of other dismissive- positive view of self, negative view of other preoccupied- negative view of self, positive view of other fearful- negative view of self, negative view of other prototype-insecurity classification model in 2012 maunder and hunter combined the internal working model with the attitudes, behaviours and emotional expression of the different styles to create a prototype based classification that included severity of insecurity. this model was designed to be clinically useful, allowing healthcare providers to identify and predict the behaviours of patients whose attachment systems were activated by pain and illness. they distinguish the different attachment styles by; 1) attachment anxiety, the discomfort someone feels when separated, 2) attachment avoidance, which is discomfort associated with closeness and 3) severity of insecurity secure- low anxiety, low avoidance, low severity of insecurity dismissive- low anxiety, high avoidance, moderate insecurity preoccupied- high anxiety, low avoidance, moderate insecurity fearful- high anxiety, high avoidance, high insecurity disorganized- high anxiety, high avoidance, high insecurity. the difference between disorganized and fearful is that people with disorganized attachment do not use a consistent strategy to find security. attachment and health outcomes attachment and health interact on multiple levels. attachment is a biologically based system tied to our response to distress and attachment styles appear to confer differences in stress physiology. illness and pain themselves act as an "activating signal" for attachment systems, and health care providers act as attachment figures in their role addressing illness and pain. accordingly, attachment styles influence patient perception of illness, health care utilization, medication compliance and treatment response. physical health while strong social support has been linked to greater resilience to stress and lower medical morbidity and mortality, the mechanism behind this association is poorly understood. in the late 1990s, paul ciechanowski investigated the role of attachment styles in patients managing diabetes, finding that individuals with an avoidant-dismissive style were less likely to be compliant with treatment recommendations and had less well-controlled disease as measured by glycated hemoglobin. larger scale evidence comes from a large american survey of self-reported attachment styles and physical illness conducted by mcwilliams and bailey. they found that those with insecure attachment reported more physical illness than securely attached individuals. specifically, they found preoccupied individuals reported more heart disease, and dismissive individuals more pain conditions. a prospective study followed children until the age of 32 and found a similar pattern of results. they found that people with anxious-resistant (dismissive) styles of attachment reported vague, non-specific symptoms more often, and those with anxious-preoccupied classification had a higher rate of inflammation-based illnesses. this prospective study was particularly important because of the difficulty assigning causation in the often observed relationship between chronic pain and insecure attachment. further support is derived from experimental pain studies that have demonstrated numerous risk factors for the development of a chronic pain disorder associated with insecure adult attachment including lower perceived control of pain, higher pain catastrophizing and higher perceived pain intensity. mental health attachment theory can be conceptualized as a theory of emotional regulation. bowlby predicted that insecure attachment would be a risk factor for mental health difficulties based on ineffective, or overly rigid, strategies for reducing distress and maintaining psychological resilience. there is a substantial body of literature that supports an association between adult insecure attachment and a wide variety of mental health disorders including depression, anxiety, eating, psychotic and personality disorders. prospective evidence (research starting with infant attachment and following up over time) is mostly limited to studies following infants into childhood or adolescence as opposed to adulthood, but does demonstrate that insecure attachment is a general risk factor for both internalizing and externalizing symptomatology. of the handful of studies that have followed infants to adulthood, the only two clear relationships that exist are between (1) disorganized attachment and dissociative symptoms and (2) resistant attachment and anxiety disorders in late adolescence. causal relationships between insecure attachment and mental illness may be complex. some risk factors for insecure attachment such as loss of parental figure, and sexual or physical abuse, are also risk factors for mental health disorders. self-report measures of attachment may be biased by mental health conditions. for example, clinical depression is often associated with negative thoughts about the self, and this cognitive bias may influence the self-report in attachment questionnaires. there may be interpersonal consequences from untreated mental health conditions. pre-existing psychological problems can increase the likelihood of secure attachment changing to insecure attachment over time. mechanisms by which attachment influences health maunder and hunter outline 3 ways in which insecure attachment can serve as a risk factor for health problems: 1) it may increase one's susceptibility to stress by changing stress physiology, 2) it may be related to potentially harmful behaviours undertaken to regulate affect, and 3) it may change the way people interact with the healthcare system. attachment and stress