A Review of The Evidence Linking Adult Attachment Theory and Chronic Pain

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Clinical Psychology Review 28 (2008) 407 429
A review of the evidence linking adult attachment theory and chronic

pain: Presenting a conceptual model
Pamela Meredith a,, Tamara Ownsworth b , Jenny Strong a
a
Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The University of Queensland,
St Lucia Queensland, 4072, Australia
b
School of Psychology, Griffith University, Mt Gravatt Campus, Nathan Queensland, 4111, Australia
Received 22 February 2007; received in revised form 20 June 2007; accepted 3 July 2007
Abstract
It is now well established that pain is a multidimensional phenomenon, affected by a gamut of psychosocial and biological
variables. According to diathesisstress models of chronic pain, some individuals are more vulnerable to developing disability
following acute pain because they possess particular psychosocial vulnerabilities which interact with physical pathology to impact
negatively upon outcome. Attachment theory, a theory of social and personality development, has been proposed as a
comprehensive developmental model of pain, implicating individual adult attachment pattern in the ontogenesis and maintenance
of chronic pain. The present paper reviews and critically appraises studies which link adult attachment theory with chronic pain.
Together, these papers offer support for the role of insecure attachment as a diathesis (or vulnerability) for problematic adjustment
to pain. The Attachment-Diathesis Model of Chronic Pain developed from this body of literature, combines adult attachment theory
with the diathesisstress approach to chronic pain. The evidence presented in this review, and the associated model, advances our
understanding of the developmental origins of chronic pain conditions, with potential application in guiding early pain intervention
and prevention efforts, as well as tailoring interventions to suit specific patient needs.
2007 Elsevier Ltd. All rights reserved.
Contents
1.
2.
3.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chronic pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2.1. Models of chronic pain . . . . . . . . . . . . . . . . . . . . . . . .
A brief orientation to attachment theory . . . . . . . . . . . . . . . . . . .
3.1. Origins of attachment theory . . . . . . . . . . . . . . . . . . . . .
3.2. Adult attachment theory. . . . . . . . . . . . . . . . . . . . . . . .
3.2.1. Measurement of adult attachment pattern . . . . . . . . . .
3.3. Clinical relevance of adult attachment theory . . . . . . . . . . . . .
3.3.1. Adult attachment theory and health behaviors and outcomes
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Corresponding author. Division of Occupational Therapy, The University of Queensland, St Lucia Queensland, 4072, Australia. Tel.: +61 7 3365
2649; fax: +61 7 3365 1622.
E-mail addresses: p.meredith@uq.edu.au (P. Meredith), t.ownsworth@griffith.edu.au (T. Ownsworth), j.strong@uq.edu.au (J. Strong).
0272-7358/$ - see front matter 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.cpr.2007.07.009
408
4.
P. Meredith et al. / Clinical Psychology Review 28 (2008) 407429
A review of the literature linking adult attachment theory and pain

4.1. Studies employing an attachment framework to explain pain
4.2. Empirical investigations of attachment theory and pain . . .
5. An attachment-informed model of chronic pain. . . . . . . . . . .
5.1. The Attachment-Diathesis Model of Chronic Pain. . . . . .
5.1.1. Model Part B: cognitive appraisals . . . . . . . . .
5.1.2. Model Part C: responses to cognitive appraisals . .
5.1.3. Model Part D: impact on adjustment . . . . . . . .
5.1.4. Mediation/moderation. . . . . . . . . . . . . . . .
6. Implications for intervention . . . . . . . . . . . . . . . . . . . .
6.1. Prevention . . . . . . . . . . . . . . . . . . . . . . . . . .
6.2. Early intervention and treatment . . . . . . . . . . . . . . .
7. Further research . . . . . . . . . . . . . . . . . . . . . . . . . . .
8. Summary and conclusions . . . . . . . . . . . . . . . . . . . . .
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction
Although adult attachment theory has increasingly been linked theoretically and empirically with perceptions of,
and capacity to cope with pain, a comprehensive review of the available evidence in this field has not yet been
presented. This paper addresses this shortfall by summarizing and critically evaluating this body of literature. In
order to facilitate this analysis, preliminary consideration is given to the chronic pain and attachment literatures. A
conceptual model is then presented which (a) serves to integrate this evidence, and (b) provides a framework for
further research.
2. Chronic pain
Pain is now widely accepted as a multidimensional construct impacted by identifiable biological, psychological and
social factors (Nicassio, Schuman, Kim, Cordova, & Weisman, 1997; Truchon, 2001). Pain refers to An unpleasant
sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such
damage (Merskey & Bogduk, 1994, p. 210). Chronic pain has been variably defined as pain that persists beyond the
normal healing time (Bonica, 1953) and pain persisting for more than six months (with or without obvious pathology)
(Zasler, Martelli, & Nicholson, 2005). In practice, however, chronicity is frequently attributed to pain persisting for
more than two or three months. Indeed, for nonmalignant pain, three months represents the most convenient point of
division between acute and chronic pain (Merskey & Bogduk, 1994, p. xi).
Investigations of the psychosocial factors associated with vulnerability for, and adjustment to, chronic pain, have
proliferated (Gatchel & Turk, 1999). Many psychosocial variables have been found to successfully predict both
chronicity of pain and severity of pain-related disability, with some (e.g., pain self-efficacy, catastrophizing) proving to
be more effective predictors of disability than either medical diagnosis or pain intensity (Arnstein, 2000). As noted by
Ciccone and Lenzi (1994) psychological and social factors are found to mediate many symptoms linked with painrelated disability, highlighting the need to address psychosocial factors during any evaluation and treatment program
for chronic pain.
2.1. Models of chronic pain
The extent of factors implicated in chronic pain has resulted in a search for a model that can represent the complex
associations and interactions between pain characteristics and the diversity of biopsychosocial variables. The ecologic
model of chronic pain by Dworkin, Wilson, and Massoth (1994), for example, emphasizes the initial role of
physiologic signals, followed by perception, appraisal, and emotional arousal, and finally the resultant pain behavior.
More recently, the Psychobiological Model of Chronic Pain (Flor & Hermann, 2004) has detailed a range of:
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(a) predisposing factors, (b) eliciting stimuli and responses, and (c) maintaining processes, that contribute to psychophysiological and pain responses.
Chronic pain impacts on almost every aspect of life, giving rise to innumerable potential stressors (Pinkus &
Williams, 1999). In the diathesisstress model of pain proposed by Gatchel and Weisberg (2000), pain, as a potential
stressor, exacerbates existing personality factors which impact upon coping responses that, in turn, impact on painrelated disability and heighten the experience of chronic pain. The Integrative Biopsychosocial Model of Low Back
Pain (Truchon, 2001), a comprehensive stress-coping model of chronic pain, is of particular relevance to this review.
According to this model, chronic activity of the body's stress mechanisms leads to maladaptive health behaviors,
negative affective states, and a biological response that has detrimental implications for health. Truchon (2001)
proposed that pain chronicity is more likely if the total demands faced by the individual are negatively perceived,
personal resources are inadequate to cope with this perceived threat, and a negative emotional response occurs.
Although Truchon's model is comprehensive, it falls short of proposing the origin of individual tendencies to adopt
particular perceptions and coping strategies, and to experience specific affective responses to stress.
Although each of these models offers some guidance for primary prevention, early intervention, and treatment
planning and implementation, they unfortunately appear to have inspired little empirical investigation. Truchon (2001)
has outlined two further limitations to existing biopsychosocial models of chronic pain. Firstly, they are based on crosssectional data and therefore do not assist in understanding causality, and secondly, they are either limited in their scope
or are too comprehensive and over-inclusive to render them suitable for empirical validation.
A further challenge for these models is the need to take into consideration the heterogeneity of individuals within the
pain population. It has been recognized that psychosocial characteristics can be used to identify subgroups of patients
that adjust differentially to their pain condition and respond variably to pain management interventions, regardless of
demographic variables, chronicity of pain, and medical diagnosis (Strong, Ashton, & Stewart, 1994; Tan, Jensen,
Robinson-Whelan, Thornby, & Monga, 2001; Turk, 1990). Arguably the most prominent psychosocial cluster model
of pain is The Multiaxial Assessment of Pain (MAP, Turk & Rudy, 1988, 1990a). In this three-category model,
individuals were labeled adaptive copers, dysfunctional, and interpersonally distressed (Turk & Rudy, 1990a).
While empirical and clinical evidence of different clusters of patients with chronic pain is now widely accepted, and
there is some evidence of the clinical utility of adopting cluster approaches to treatment (Turk, 2005), there has been no
exploration of the relative clinical value of any particular cluster model. Further, no explanation or investigation of the
origin of these clusters has been provided.
In 1994, Ciccone and Lenzi called for a heuristic model of chronic pain, founded on a more general theory of human
behavior, to explain the psychological factors underlying vulnerability to chronic pain. Clearly, to have clinical value
such a model should also have the potential (like the MAP) to identify heterogenous clusters of pain patients. These
clusters of individuals, likely to report common vulnerabilities, are therefore likely to require more similar styles of
intervention. Attachment theory has been proposed to have such heuristic value in understanding the behavior of
patients with chronic pain syndromes (Kolb, 1982). The next section provides an orientation to attachment theory,
followed by a review of the literature and evidence linking attachment theory to chronic pain.
3. A brief orientation to attachment theory
3.1. Origins of attachment theory
John Bowlby (1969/1997) conceptualized attachment theory as a theory of social and emotional development with
life-long applicability, later claiming it to be the best supported theory of socio-emotional development yet available
(Bowlby, 1988, p. 28). Indeed, Thomas (2005) acclaimed it as the most widely accepted and validated approach in
developmental psychology. The attachment system, thought to organize emotion and behavior throughout life,
develops through an interaction between the child's developing cognitive capacities and their caregivers' responses
within the environmental context (Waters & Cummings, 2000). Infants are considered to have a biological drive to
maintain proximity to their caregiver and to resist separations, particularly in the face of threat. In response to stressors
such as pain, fatigue, fearful events, and separation from attachment figures, infants use specific behaviors, labeled
attachment behaviors, to gain proximity to the caregiver and to achieve felt security (Bowlby, 1988). Main (2000)
has suggested that, while early attachment behaviors such as crying and smiling are innate, later attachment behaviors
reflect organized and conditioned strategies for maintaining closeness and security with the attachment figure.
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The key factor in the development of a healthy personality is the consistency and appropriateness of the responses
of primary caregivers towards the developing infant (Bowlby, 1969/1997). The felt security associated with an
adequate attachment relationship is deemed to provide a safe environment in which to practice and develop a range of
difficult skills, including the regulation of emotions (Simpson & Rholes, 1994). These early relationship experiences
result in the development of the internal working model (Bowlby, 1969/1997, 1988), which is a template upon which
future interactions are based. The internal working model has been described as a complex cognitiveemotional
schema of self and others that influences future perceptions, emotions, and interactions (Mikulincer, 1995). Bowlby
(1980) emphasized that these models act as a filter for the way in which we construct every situation, which, in turn,
affects the way we feel.
In the earliest empirical investigations of attachment theory in infants Ainsworth (1964, 1973, 1979, 1982)
identified and labeled three main styles of infant attachment, namely, secure, insecure-avoidant and insecure-resistant
(or anxious-ambivalent) (for a comprehensive review see Karen, 1994/1998). These three attachment styles have
become the key framework of early childhood attachment, although Main (2000) later identified a fourth category
known as insecure-disorganized. A more in-depth review of childhood attachment is beyond the scope of the present
literature review, which primarily focuses on the more recent conceptualization of adult attachment.
3.2. Adult attachment theory
Bowlby (1969/1997) posited attachment-based internal working models as having life-long application. In addition
to infancy and early childhood, the construct of attachment has also been applied to later childhood (Main, 2000),
adolescence (Cassidy, Ziv, Mehta, & Feeney, 2003), and adulthood (Ainsworth, 1989; Bartholomew & Horowitz,
1991; Hazan & Shaver, 1987; Main, Kaplan, & Cassidy, 1985). Further, longitudinal studies have revealed evidence of
relative stability in attachment characteristics over time (Baldwin & Fehr, 1995; Bar-Hain, Sutton, Fox, & Marvin,
2000; Hamilton, 2000; Lewis, Feiring, & Rosenthal, 2000; Moss, Cyr, Bureau, Tarabulsy, & Dubois-Comtois, 2005;
Waters, Hamilton, & Weinfield, 2000; Weinfield, Sroufe, & Egeland, 2000).
3.2.1. Measurement of adult attachment pattern
Although attachment-based internal working models were viewed as having life-long application, the interview
nature of early measures of attachment in adulthood were lengthy, required specialist training to administer, and were
thus less practical for research purposes (Brennan, Clark, & Shaver, 1998). This delayed empirical investigation of the
adult attachment construct. In the late 1980's Hazan and Shaver's seminal research gave rise to a simple, three-level
categorical self-report measure. Hazan and Shaver (1987) labeled three adult attachment categories as secure,
anxious-ambivalent, and avoidant. The concept of attachment applied to adulthood has since developed into a
complex construct with various measurement approaches and a diverse body of empirical findings (Feeney, Noller, &
Hanrahan, 1994). The range of self-report measures now available has lead to some debate regarding the relative value
of categorical (typological) as opposed to continuous (dimensional) measures of adult attachment (Fraley & Waller,
1998).
Presently, the most widely accepted categorical conceptualization of adult attachment recognizes four attachment
categories defined by the individual's perception of self and perception of others: secure, fearful, preoccupied
and dismissing (Bartholomew, 1990; Bartholomew & Horowitz, 1991). Secure attachment, constituting a positive
cognitive representation of self and of others, has more adaptive implications for adjustment and well-being in
stressful situations compared to any of the three insecure orientations, namely preoccupied, dismissing, and fearful
(Mikulincer & Florian, 1998). Preoccupied attachment, also called anxious-ambivalent attachment, suggests positive
cognitive representations of others and negative representations of self, while the reverse is true of dismissing
(dismissing-avoidant) attachment, with negative models of other and a positive model of self. Those with a fearful
(fearful-avoidant) attachment style display negative models both of others and of the self (Bartholomew & Horowitz,
1991). While these four attachment styles are measured categorically, provision is also made for these four categories
to be measured continuously using this measure (Bartholomew & Horowitz, 1991). Thus, an individual can report
being more like or less like each of these prototypes.
Investigations of the structure underlying continuous adult attachment measures such as the Attachment Style
Questionnaire (ASQ, Feeney et al., 1994) have consistently revealed two main adult attachment dimensions labeled
discomfort with closeness (avoidance) and anxiety over relationships (relationship anxiety). These two dimensions are
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conceptually similar to the model of other (avoidance) and model of self (anxiety) dimensions proposed by Bartholomew
and Horowitz (1991). Similar dimensions of adult attachment, derived from other attachment questionnaires, have also
been reported (Bartholomew & Shaver, 1998; Brennan & Shaver, 1995). Some researchers argue that the attachment
categories are not mutually exclusive, and that dimensional assessment methods might afford a more accurate
representation of the adult attachment construct than that provided by the categorical (or style) measures (Fraley &
Waller, 1998). However, both categorical and dimensional models are theoretically defensible (Fraley & Waller, 1998).
3.3. Clinical relevance of adult attachment theory
Individual differences in attachment security have been linked to a range of clinically relevant phenomena. These
include: (a) quality of intimate relationships (Feeney & Noller, 1996); (b) depression (Bifulco, Moran, Ball, &
Bernazzani, 2002) (c) postnatal depression (Meredith & Noller, 2003); (d) self-esteem (Feeney & Noller, 1990);
(e) anger and hostility (Troisi & D'Argenio, 2004); (f) coping skills (Feeney & Kirkpatrick, 1996; Schmidt, Nachtigall,
Wuethrich-Martone, & Strauss, 2002); (g) communication and marital satisfaction (Feeney, Noller, & Callan, 1994);
(h) career choice and satisfaction (Roney, Meredith, & Strong, 2004); (i) attributional style and history of suicidal
ideation (Armsden, McCauley, Greenberg, Burke, & Mitchell, 1990); (j) psychosis (Berry, Barrowclough, & Wearden,
2007), (k) borderline personality disorder (Agrawal, Gunderson, Holmes, & Lyons-Ruth, 2004), and (l) health
behaviors (Ciechanowski, Katon, Russo, & Dwight-Johnson, 2002; Feeney, 1995; Feeney & Ryan, 1994; Hunter &
Maunder, 2001; Maunder & Hunter, 2001; Maunder, Lancee, Nolan, Hunter, & Tannenbaum, 2006; Schmidt,
Nachtigall et al., 2002; Taylor, Mann, White, & Goldberg, 2000). Investigations of attachment security and health
behaviors have particular relevance to chronic pain.
3.3.1. Adult attachment theory and health behaviors and outcomes
Hunter and Maunder (2001) detailed an adult attachment model of illness behavior, viewing medical illness (e.g.,
diabetes) or surgery as a stressor, which activates a unique set of attachment behaviors which, in turn, influence the
responses of health professionals (Hunter & Maunder, 2001). Hunter and Maunder (2001) described securely attached
people as appropriately able to modulate and express affect, and as having adequate resilience to manage illness-related
distress. Those with anxious attachment styles were deemed to possess poor affect regulation, high affective
expression, and a drive to depend on others. Overt expressions of distress for this subgroup of individuals were seen as
efforts to engage treating professionals, and the model predicted that anxiously attached individuals would present as
needy and dependent. Individuals with avoidant attachment, suggestive of over-modulation of affect, were predicted to
appear undemanding, with little evidence of emotion, and therefore to present as unproblematic to professionals.
However, their behavior, which might include underreporting symptoms and resisting medical interventions and
advice, was posited to interfere with treatment (see also Maunder & Hunter, 2001).
In the health field, attachment patterns have been empirically linked to (a) symptom reporting and accessing health
care (Ciechanowski, Walker, Katon, & Russo, 2002; Feeney & Ryan, 1994); (b) unexplained physical symptoms
(Taylor et al., 2000); (c) quality of the patientprovider relationship and treatment adherence (Ciechanowski, Katon, &
Hirsch, 1999; Ciechanowski, Katon, Russo, & Walker, 2001); (d) satisfaction with weight and nutrition, level of
exercise, and ability to implement lifestyle change (Feeney, 1995); (e) etiology of ulcerative colitis (Maunder, Lancee,
Greenberg, Hunter, & Fernandez, 2000); and (f) likelihood of developing breast cancer in women (Tacon, 2003).
Overall, this body of literature highlights several benefits of adopting an attachment theory perspective for chronic
pain. First, attachment theory offers a comprehensive developmental model with established implications for
understanding a range of illness behaviors. Second, the maladaptive behaviors, emotions and cognitions associated
with attachment insecurity potentially explain why some people may be more vulnerable to developing chronic pain
conditions. Finally, the use of attachment theory to identify distinctive subgroups of individuals in pain and explain
differential responses to treatment, might potentially inform the development of tailored intervention approaches. The
next section addresses the theoretical and empirical literature linking pain and attachment.
4. A review of the literature linking adult attachment theory and pain
In 1982, Kolb made one of the earliest links between attachment and pain, using attachment theory to explain a
range of behaviors commonly observed in patients presenting with pain complaints. In a paper based largely on clinical
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observations, Kolb (1982) defined pain complaining as an attachment behavior that is, a behavioral rule learned in
infancy and utilized later in life in an effort to elicit responses from caregivers. More specifically, Kolb (1982)
suggested that, for those with chronic pain, a diverse range of attachment behaviors may be displayed, which include
complaining, clinging, questioning, making demands, withdrawing, criticizing professionals, denying distress,
threatening to cease treatment, erratic appointment attendance, high levels of help seeking from different specialists,
and showing impulsivity, despair, anger and depression. Kolb saw pain complaining as a cry for security, and
emphasized that, irrespective of biological contributions to the reported pain, this cry must be heeded by practitioners
in order for intervention to be successful. Kolb labeled shopping for interventions as attachment searching (1982,
p. 416), which he suggested might result from failure to form a secure therapeutic relationship with health specialists.
He viewed persistent pain complaints as a warning sign for poor social attachments, and suggested that patients
engaging in this behavior tend to have highly dependent personalities. These speculations motivated little empirical
research, however, and for the next decade, the literature was silent on the implications of attachment theory for pain.
Then, in 1994, Anderson and Hines presented an attachment-based model of pain in which they proposed that
attachment theory provides a sound theoretical framework for psychogenic pain (i.e., pain which is disproportionately
severe given the known physical pain stimulus). They suggested that the patient's attachment history is at the centre of
both the individual's vulnerability to developing chronic pain and the pain experience, and that chronic pain represents
a plea for assistance in confronting earlier unresolved traumas. Anderson and Hines (1994) also drew attention to the
dependency on others that can be imposed by chronic back pain, and suggested that anxiety accompanying spinal pain
might evoke attachment behaviors. For those individuals lacking secure attachment histories, chronic pain may prove
not only a source of considerable distress, but may restrict participation in relationships and activities that may have
been supportive and comforting. Further, the internal resources of those with an insecure attachment pattern are often
inadequate to cope with this level of distress, leaving the patient inconsolable. In particular, Anderson and Hines
highlighted the need to be mindful of the tendency for insecurely attached patients to evoke negative responses in
others, consistent with their own internal expectations.
Mikail, Henderson, and Tasca (1994) concurrently proposed attachment theory as a model for understanding the
development of, and adaptation to, chronic pain, claiming that intrapsychic and environmental variables serve as
vulnerability factors for the development of chronic pain syndromes. These authors noted that attachment theory allows
for identification of subgroups of chronic pain patients, and suggested a range of treatment considerations for these
groups. The increased vulnerability to stress of insecurely attached adults was emphasized. In particular, it was
proposed that those with preoccupied and fearful styles, having a negative perception of self, are uncertain of their
ability to deal with the threat invoked by chronic pain or the associated negative affect.
Mikail et al. (1994) also predicted attachment-related differences in areas such as appraisal of pain, health care
support-seeking, general support-seeking, self-disclosure, ability to express concerns, emotionality, treatment
compliance, doctor shopping, and symptom-focus. For example, it was suggested that securely attached patients
would be less susceptible to developing chronic pain, and would respond more favourably to interventions. Patients
with a dismissing attachment style were predicted to avoid reporting problematic pain until the advanced stages, and to
view others as unavailable, tending to seek multiple and superficial consultations. Health professionals were
considered likely to perceive dismissing patients as coping adequately, or as unlikely to be cooperative with treatment,
and thus discharge them from care. Fearful patients were predicted to present only when desperate, with a high
likelihood of secondary, exacerbating conditions complicating the clinical picture. They were considered likely to
present as helpless and hopeless, resulting in a tendency for health professionals to recommend psychological
interventions, which would be perceived by the patient as a sign of rejection. Progress for the fearful group in pain
rehabilitation was predicted to be negligible. Finally, those with a preoccupied style were considered likely to seek care
and to initially idealize the health professional. Ambivalence might then emerge as a challenge to, rejection of, or even
sabotaging of, treatment.
Taken together, these three attachment-based theoretical perspectives of pain (Anderson & Hines, 1994; Kolb, 1982;
Mikail et al., 1994) have portrayed insecurely attached individuals as: (a) at greater risk of developing chronic pain;
(b) less able to internally manage the distress associated with pain; (c) less able to procure and maintain external
supports; (d) less able to form secure therapeutic alliances; (e) perceiving more negative intent in health professionals;
(f) evoking more negative responses from health professionals; and (g) possibly sabotaging therapeutic efforts. Thus,
insecure attachment was viewed as a vulnerability factor likely to predict problematic adjustment to pain and poorer
outcomes from a range of treatment interventions.
413
4.1. Studies employing an attachment framework to explain pain

A number of pain studies have utilized an attachment framework to explain their pattern of findings, while not
investigating attachment status directly (e.g., Felitti et al., 1998; Goldberg & Goldstein, 2000; Katon, Sullivan, &
Walker, 2001; Schofferman, Anderson, Hines, Smith, & Keane, 1993; Walker, Keegan, Garnder, Sullivan, Bernstein
et al., 1997; Walker, Keegan, Garnder, Sullivan, Katon et al., 1997; Walker et al., 1999; Yucel, Kora, Ozyalcin, Alcalar,
Ozdemir, & Yucel, 2002). Walsh, Symons, and McGrath (2004) found similarities in children's reactions to both
separations from caregivers and pain experiences. Children's expressions of vulnerability, self-confidence or avoidance
of separations mirrored their responses to pain. This finding was interpreted as support for the hypothetical construct
of an internal working model of attachment which organizes children's behaviors, thoughts and feelings in response to
both separation experience and painful events (Walsh et al., 2004, p. 53). In a neuro-imaging study with young adults,
Eisenberger, Lieberman, and Williams (2003) found evidence in support of this suggestion. Findings revealed that
physical pain and the pain related to rejection (or social separation) share similar neuro-anatomical mechanisms,
suggesting that the attachment system and pain conditions have a similar physiological basis.
4.2. Empirical investigations of attachment theory and pain
A limited number of studies (summarized in Table 1) have empirically investigated the proposed links between
attachment pattern and the pain experience.
Taken together, these studies suggest that, compared to individuals that are securely attached, insecurely attached
people with chronic pain engage in more emotion-focused and less problem-focused coping (Mikulincer & Florian,
1998), describe their pain as more threatening and themselves as less capable of dealing with it (Meredith, Strong, &
Feeney, 2005; Mikulincer & Florian, 1998), and report greater pain intensity and disability (McWilliams, Cox, & Enns,
2000) and greater migraine-related disability (Rossi et al., 2005). Insecurely attached individuals also report more painrelated distress (Pearce, Creed, & Cramond, 2001), more physical symptoms (Schmidt, Nachtigall et al., 2002), higher
levels of pain-related stress, anxiety, depression and catastrophizing (Ciechanowski, Sullivan, Jensen, Romano, &
Summers, 2003; Meredith et al., 2005; Meredith, Strong, & Feeney, 2006a; Meredith, Strong, & Feeney, 2007), and
lower pain self-efficacy (Meredith et al., 2006a). In addition, individuals vary in their response to acute, laboratoryinduced pain according to attachment variables, with insecure attachment associated with various vulnerability factors
including: depression, decreased pain control, catastrophizing, pain-related fear, hypervigilance to pain, and more
negative pain affect (MacDonald & Kingsbury, 2006; McWilliams & Asmundson, 2007; Meredith, Strong, & Feeney,
2006b).
The consistency in findings across this range of psychosocial variables improves confidence in the robustness
and external validity of the associations. However, while findings from these studies are largely consistent with
the theoretical view that insecure attachment bodes negatively for those in pain, critical appraisal of this small
body of evidence highlights several areas that warrant further attention. First, the methodologies of this diverse body
of studies were heterogeneous in terms of the sampling approach, and use of categorical or continuous attachment measures and outcome measures, thus making it difficult to draw conclusions about the generalizeability of
findings.
Second, it is important to acknowledge the potential biases impacting the studies considered in this review (see
Howell, 2001). Selection bias in particular is difficult to overcome in clinical research, and the voluntary nature of
participation limits the conclusions that can be drawn. For example, it was noteworthy that significantly more secure
individuals (higher comfort with closeness, lower fearful attachment) completed questionnaires both before and after
treatment, compared with those who completed only pre-treatment questionnaires (Meredith et al., 2007). This
suggests that insecurely attached individuals may be underrepresented in the samples studied, and that results represent
a conservative estimate of the impact of attachment insecurity on adjustment to chronic pain. Similarly, those attending
a pain treatment facility cannot be assumed to represent the population of individuals experiencing chronic pain
(Turk & Rudy, 1990b).
Third, several additional methodological concerns were identified, including the failure to report methodology (e.g.,
Mikulincer & Florian, 1998; Pearce et al., 2001), the tendency for studies to base findings upon secondary or
retrospective analyses in which exploration of the relationship between attachment variables and pain was not the
primary objective (e.g., Ciechanowski et al., 2003; McWilliams et al., 2000; Schmidt, Nachtigall et al., 2002), and the
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Table 1
Empirical studies investigating the relationship between attachment style and chronic pain
Sample
Research design
Attachment measures
Chronic pain and psychosocial variables Main outcomes
Mikulincer and
Florian (1998)
N = 170
85 Males with low back
pain for N6 months, and 85
matched males with no pain.
Cross-sectional
Attachment Self-Report (ASR,

Hazan & Shaver, 1987) 3
categories.
Mental Health Inventory (Veit &

Ware, 1983) psychological
distress.
Pain Appraisal Scale
(Lazarus & Folkman, 1984)
threat or ability appraisal.
Ways of Coping Checklist
(Folkman & Larazus, 1985)
emotion-focused and problemfocused coping.
No pain variables reported.
McWilliams
et al. (2000)
N = 381
A secondary analysis of
data from a national US
psychiatric survey, which
selected those with severe
arthritis, rheumatism,
bone or joint disease.
1554 years. 52.4%
female.
N = 200
Individuals with chronic
pain syndrome attending
a pain education program.
Cross-sectional,
face-to-face,
in-home
questionnaire
administration
Attachment Self-Report (ASR,

Hazan & Shaver, 1987) 3
categories and 3 continuous
scales.
Cross-sectional
Revised Adult Attachment Scale

(RAAS; Collins & Read, 1990).
Findings used secure and
insecure categories only.
N = 1997
883 Males, 1114 females.
A secondary analysis of a
German national survey
covering general bodily
complaints.
Cross-sectional
Revised Adult Attachment Scale

(RAAS, Collins & Read, 1990;
German version, Buesselberg,
1997). Five latent attachment
classes were identified.
Extent of pain one question.

Extent of disability one
question.
Composite International
Diagnostic Interview
Modified (World Health
Organization, 1990)
assessment of major depressive
disorder.
McGill Pain Inventory
(Melzack, 1975) sensory,
affective, evaluative, miscellaneous
and overall distress.
Potential confound variables:
Pain intensity
Pattern of pain
Age
Gender
Giessen Subjective Complaints
List (GSCL, Braehler &
Scheer, 1995) includes gastric
complaints, limb pain,
cardiac complaints, fatigue, skin
complaints, digestive trouble,
abdominal complaints.
Whiteley Index (Pilowsky, 1967)
fear of disease, bodily
pre-occupation, disease conviction.
Pearce et al.
(2001)
Schmidt, Strauss,
and Braehler
(2002)
Avoidant and anxious-ambivalent men

with low back pain for more than six
months reported more psychological
distress than either pain-free or
secure men.
Secure men reported fewer mental
health problems than insecure men.
Secure men in pain appraised their pain
as less threatening, themselves as more
able to deal with the pain, and
reported more problem-focused and
less emotion-focused coping
strategies, compared with either of
the insecure groups.
Pain severity and anxious attachment
together accounted for 20.3% of the
variance in extent of disability, with
no other variables found to be
significant.
The analysis identified 54 secure, and 146

insecure individuals.
Secure individuals reported less overall
distress compared to insecure
individuals.
Potential confound variables were
not significantly associated with
attachment security.
The two anxious latent attachment classes
reported highest symptom levels on almost
all scales.
No differences on the dependent
variables were detected among the
other three scales.
The anxious/fear of loss class reported the
highest amount of pain symptoms, fear of
disease, and conviction of suffering from a
serious disease.
Study
Longitudinal.
Data obtained
pre- and 12 month
post-treatment.
Attachment
measured 528
month posttreatment (i.e.,
retrospectively)
Relationship Scale Questionnaire

(RSQ, Griffin & Bartholomew,
1994) secure, fearful,
pre-occupied, and dismissing.
Low to moderate internal
consistencies of .30 to .64.
N = 111
A secondary analysis of data
from patients in chronic
pain attending an outpatient
pain treatment program.
Rossi et al.
(2005)
N = 200
Cross-sectional
Participants with episodic or
chronic migraine at a specialty
headache clinic. 73% women.
73% employed.
Attachment Style Questionnaire

(ASQ, Feeney et al., 1994)
5 scales
Meredith et al.
(2005)
N = 141
Participants with chronic
Cross-sectional
Relationship Questionnaire
(RQ, Bartholomew & Horowitz,
1991) 4
attachment styles.
two attachment dimensions
(comfort with closeness and
relationship anxiety).
Catastrophizing subscale of the

Coping Strategies Questionnaire
(CSQ, Rosenstiel & Keefe, 1983).
Center for Epidemiological
Studies-Depression
Scale (CES-D, Radloff, 1977).
RolandMorris Disability
Questionnaire (RMDQ,
Roland & Morris, 1983).
Health care utilization during
the three-month period prior to
each assessment.
Pain intensity rating scale
(Jensen & Karoly, 2001).
Beck Depression Inventory
(BDI, Beck, Steer, &
Brown, 1996).
Migraine Disability
Assessment Questionnaire
(MIDAS, Stewart, Lipton,
Kolodner, Liberman, &
Sawyer, 1999; Stewart,
Lipton, Whyte et al., 1999).
Pain intensity (from MIDAS,
Stewart, Lipton, Kolodner
et al., 1999; Stewart, Lipton,
Whyte et al., 1999).
Pain Appraisal Inventory (PAI,
Unruh & Ritchie, 1998).
Catastrophizing subscale
(CSQ-Cat, Rosenstiel &
Keefe, 1983).
Oswestry Disability Index
(Fairbank, Cooper, Davies &
O'Brien, 1980; Fairbank &
Pynsent, 2000).
Pain intensity visual analogue
scale.
Depression Anxiety Stress Scales 21
(DASS-21,
Lovibond & Lovibond,
1993, 1995)
Fearful attachment was associated with

higher levels of pre-treatment depression,
and with higher levels of post-treatment
(12 month follow-up) depression and
catastrophizing.
Neither pain intensity nor physical
dysfunction was associated with
attachment.
Overall, disability was associated with

chronic migraine, more severe
depression, more severe pain intensity, and
insecure attachment.
For those with episodic migraine, an insecure
style of attachment was the most significant
predictor of disability.
Secure attachment linked with challenge

appraisal of pain, and less catastrophizing,
depression, anxiety and stress.
Preoccupied attachment less distressed
than other styles.
Dismissing attachment linked with threat
appraisal, stress and anxiety.
Fearful attachment linked with threat appraisal,
anxiety and depression.
Comfort with closeness was strongly
linked to appraisal of the pain as a
challenge, and with less depression and
anxiety.
Anxiety over relationships, on the other
hand, was strongly associated with a
threat appraisal of the pain, and with
more catastrophizing, depression, stress
and anxiety.
415
(continued on next page)
Ciechanowski
et al. (2003)
416
Study
Sample
Research design
Attachment measures
Chronic pain and psychosocial variables Main outcomes
Meredith, Strong
and Feeney
(2006b)
N = 58
Convenience sample of
students and colleagues with
no history chronic pain.
Cross-sectional
Relationship Questionnaire (RQ,

Bartholomew & Horowitz,
1991) 4 attachment styles.
Meredith, Strong
and Feeney
(2006a)
N = 152
pain treatment program
Cross-sectional
Relationship Questionnaire (RQ,

Bartholomew & Horowitz,
1991) 4 attachment styles.
In response to experimental coldpressor

pain:
Relationship anxiety was linked with lower
pain thresholds, more stress, depression and
catastrophizing, diminished perceptions of
control over pain, and diminished perceptions
of ability to decrease pain.
Secure attachment was linked with more
stress and more control over pain, but lower
levels of depression and catastrophizing.
Preoccupied attachment linked to
catastrophizing and less pain control.
Dismissing attachment linked to higher levels
of depression and less pre-task catastrophizing.
Fearful attachment linked to pre-task
catastrophizing.
Also found that insecurely attached
individuals were more likely to catastrophize
when reporting high levels of pain.
Fearful and preoccupied attachment
Oswestry Disability Index
categories associated with low
(Fairbank et al., 1980; Fairbank &
pain self-efficacy.
Pynsent, 2000).
Pain intensity visual analogue scale. Fearful and preoccupied attachment
categories associated with low
Depression Anxiety Stress
pain-self-efficacy.
Scales 21 (DASS-21, Lovibond &
Comfort with closeness linked with high pain
Lovibond, 1993, 1995).
self-efficacy.
Pain Self-efficacy Questionnaire
All forms of insecure attachment linked with
(PSEQ, Nicholas, 1994, 2007).
higher levels of anxiety.
Comfort with closeness moderated three
Catastrophizing subscale (CSQ-Cat,
Rosenstiel & Keefe, 1983).
Scales 21 (DASS-21, Lovibond &
Lovibond, 1993, 1995).
Pain intensity pain ratings,
visual analogue scale.
Coldpressor threshold.
Coldpressor tolerance.
Table 1 (continued )
associations: (1) pain self-efficacy and

disability, (2) pain self-efficacy and pain
intensity, and (3) anxiety and disability.
Cross-sectional
Attachment Style Questionnaire Physical pain affect averaged score Higher levels of pain affect were related
MacDonald and
N=156
from two scales measuring pain severity to higher levels of anxious attachment.
Kingsbury
Participants (82 female, 73 male,
Anxious attachment fully mediated the
anxious and avoidant dimensions. and suffering as a result of pain.
(2006)
1 unknown); 64 attending
relationship between pain affect and anxiety,
Depression Anxiety Stress Scales
multidisciplinary treatment
(DASS, Lovibond & Lovibond, 1995). and partially mediated the relationship
program for chronic pain,
between pain affect and depression.
Potential confound variables:
92 respondents recruited from a
Avoidant attachment was not related to
Age.
community shopping centre.
pain affect.
Gender.
Marital Status.
Level of education.
Meredith, Strong N = 99
Longitudinal (pre- Attachment Style Questionnaire Pain intensity visual analogue
Comfort with closeness associated with less
and Feeney
to post-treatment) (ASQ, Feeney et al., 1994)
scale.
pre- and post-treatment depression.
(2007)
Anxiety over relationships was the strongest
Scales 21
predictor of pre-treatment depression,
Depression subscale
although this association diminished with
(DASS-21-Dep, Lovibond &
treatment.
Lovibond, 1993, 1995).
Comfort with closeness was the unique
predictor of lower levels of post-treatment
depression, usurping pain intensity
and pre-treatment depression.
Negative model of self (relationship
McWilliams
N = 278
Cross-sectional
Experiences in Close Relationships Fear of Pain Questionnaire-III
anxiety) associated with greater levels
and Asmundson Introductory psychology
Questionnaire (ECR, Brennan et al., (FPQ-III, McNeil &
of pain-related fear, hypervigilance,
(2007)
students receiving credit
1998) two dimensions (anxiety Rainwater, 1998).
and catastrophizing.
for participation.
and avoidance).
The Pain Vigilance and Awareness
Negative model of others (avoidance)
Questionnaire (PVAQ,
associated with increased catastrophizing.
McCracken, 1997).
The Pain Catastrophizing Scale
(PCS, Sullivan, Bishop, &
Pivik, 1995).
417
418
paucity of demographic or pain-related information in some cases (e.g., Mikulincer & Florian, 1998; Pearce et al.,
2001). Further, as can be seen in Table 1, the majority of these studies are cross-sectional. This limits the potential to
consider directionality of associations between attachment and other variables.
Measurement of attachment constitutes a fourth concern, with a wide range of measures employed. For example,
Schmidt, Nachtigall et al. (2002) employed five attachment classes developed for the purpose of their study, with no
direct parallels with the categories or dimensions from the broader attachment literature. Some studies (e.g., Pearce
et al., 2001) relied on secure and insecure attachment categories, others on three- or four-category measures (e.g.,
Ciechanowski et al., 2003; Mikulincer & Florian, 1998), and others on various continuous measures (e.g., Meredith
et al., 2007; Rossi et al., 2005). Reliance on self-report data, associated with social desirability bias, is another
measure-related concern. In addition, Ciechanowski et al. (2003) measured attachment retrospectively at various
timeframes (i.e., 528 months after treatment) and employed measures of attachment with relatively low
internal consistency (i.e., .30.64). Although their findings were replicated by Meredith et al. (2007), they must be
considered with caution because the stability of attachment style following rehabilitation for chronic pain has not
been established.
An additional concern relates to variations in terminology; for example, MacDonald and Kingsbury (2006)
operationalized pain affect as a combination of pain severity and pain-related suffering, while Meredith et al.
(2005) considered pain affect to include pain-related depression, stress, and anxiety. Thus, while preliminary evidence
of associations between attachment and pain variables is encouraging, many issues remain to be addressed.
5. An attachment-informed model of chronic pain
The empirical evidence linking chronic pain and attachment orientation is in its infancy. In order to guide
future research in this field a heuristic model of attachment and chronic pain is now described. This model is
presented with the aim of integrating the diversity of psychosocial factors in a meaningful fashion, and guiding
exploration of the relationships between these variables, thus forming the basis for developing systematic and testable
predictions.
Fig. 1. The Attachment-Diathesis Model of Chronic Pain (ADMoCP) model of proposed mechanisms linking attachment (in)security to outcome
for people with chronic pain.
419
5.1. The Attachment-Diathesis Model of Chronic Pain

Evidence from the broader attachment literature supports insecure attachment as a diathesis (or predisposition) in
the etiology of various problem behaviors and conditions, including sexual violence (Burk & Burkart, 2003), parent
child violence (Bolton, 1988), somatic symptomatology and disease (Homayounjam, 1999), eating disorders (Ward,
Ramsay, & Treasure, 2000), and depression (Parker, 1994). Although a range of psychosocial and personality variables
has been discussed as diatheses for chronic pain (Gatchel & Weisberg, 2000; Pinkus & Williams, 1999; Turk, 2002;
Weisberg & Keefe, 1999), to date the role of attachment insecurity as a diathesis for chronic pain has received little
attention. In this section, an Attachment-Diathesis Model of Chronic Pain (ADMoCP) is presented in which pain, as a
stressor, triggers attachment-related cognitive, behavioral, and emotional mechanisms. Depending on security of
attachment (the potential diathesis), different mechanisms are triggered, with implications for both the experience of
pain and adjustment to the pain.
In brief, a relationship is proposed to exist between A. adult attachment pattern and B. cognitive appraisals of (a) the
pain, (b) the self, and (c) social support, which is triggered in response to pain (the stressor). As detailed in cognitive theory
(Lazarus, 1993; Lazarus & Folkman, 1984), these appraisals then impact upon C. the responses of the person, including
their selection of coping strategies, support-seeking, emotional states, and, ultimately, D. adjustment to the pain.
In addition, attachment is proposed to moderate the impact of these psychosocial variables on adjustment to pain
(see Fig. 1).
As can be seen from Fig. 1, this model reflects a unidirectional relationship between variables. In taking this
decision, it was not intended to overlook the frequently circular (or spiral) nature of these associations, but rather to
confine otherwise exceedingly complex relationships in order to facilitate empirical consideration. In addition,
the associations between the cognitive appraisals and reactions to cognitive appraisals (Parts B and C) have not
been specified in the model since these associations have been extensively demonstrated and discussed elsewhere
(Lazarus & Folkman, 1984). Information supporting the diathesis role of individual attachment pattern (Model Part A)
has been previously outlined; the model will now be clarified with further attention to Model Parts B, C, and D,
including an examination of evidence from the reviewed literature.
5.1.1. Model Part B: cognitive appraisals
Appraisal of pain (and associated events) as a stressor relies upon the individual's perceptions that the pain is
threatening and that they are unable to cope with it (Cohen, Kessler, & Gordon, 1995; Cohen & Wills, 1985). Further,
Lazarus, Kanner, and Folkman (1980) observed the importance of an individual's perceptions, both of the self and of the
world, as determinants of the appraisal process. In this context, three areas of cognitive appraisal warrant consideration:
(1) the appraisal of pain as a threat, (2) the appraisal of the self as equipped to manage this threat, and (3) the appraisal of
others (the world) as supportive in this situation. These three appraisal factors are further considered below.
5.1.1.1. Cognitive appraisal of pain. Cognitive appraisal of pain is considered critical to the pain experience (Raak,
Wikblad, Raak, Carlsson, & Wahren, 2002; Sanford, Kersh, Thorn, Rich, & Ward, 2002; Turner, Jensen, & Romano,
2000; Unruh, 1996). Unruh and Ritchie (1998) defined appraisal of pain in terms of perceived threat or challenge. A
threat appraisal is a negative interpretation of the pain, associated with increased pain intensity, disability, emotional
distress (Unruh & Ritchie, 1998), catastrophizing (Unruh, 1996), and pain responsivity (Sanford et al., 2002). A
challenge appraisal, suggestive of an inherent resilience in the individual, has been linked with positive self-statements
(Unruh, 1996).
According to attachment theory, appraisals of threat activate the attachment system and mobilize attachment
behaviors. Empirical studies indicate that increased threat appraisals of pain are most likely to be demonstrated by
less secure individuals (Mikulincer & Florian, 1998), and those with high relationship anxiety, and dismissing and
fearful attachment styles (Meredith et al., 2005). In addition, in a laboratory study, relationship anxiety was
associated with perceptions both of diminished control over pain and diminished ability to decrease pain (Meredith
et al., 2006b).
5.1.1.2. Self-appraisal. Appraisal of the self as equipped to cope with the stress of pain is critical to successful
adaptation (Cohen & Wills, 1985; Lazarus et al., 1980). Self-efficacy was defined by Arnstein (2000) as the evaluation
of one's ability to perform particular behaviors in particular situations, and includes confidence in one's ability to
420
perform tasks as well as one's persistence in the face of pain (Nicholas, 2007). Self-efficacy is believed to influence the
effort and the level of participation a person invests in an activity (Strong, 1995), with individuals more likely to
comply with activities they believe they can perform successfully (Turner et al., 2000). Pain self-efficacy has been
convincingly related to extent of pain behavior and avoidance behavior (Asghari & Nicholas, 2001), pain intensity
(Arnstein, 2000), coping with pain (Turner et al., 2000), and functional status (Strong, 1995).
Bowlby (1977) originally suggested that insecure attachment was akin to learned helplessness (Seligman, 1972) in
that insecurely attached individuals have learned that they are helpless to alter their circumstances. More recently,
Mikulincer (1995) suggested that the negative self-image held by those with high attachment anxiety might result in
their perception that they are incapable both of producing positive outcomes and of preventing the loss of positive
circumstances. To date, only one investigation has considered this issue in the attachment/pain literature. Meredith et al.
(2006a) found that, consistent with expectations, fearful and preoccupied (i.e., anxious) attachment was linked
with low levels of pain self-efficacy, while those high on the comfort with closeness dimension indicated high pain
self-efficacy.
5.1.1.3. Cognitive appraisal of social support. The belief that adequate support is available from others has
consistently been predictive of successful adjustment, coping and well-being (Sarason, Levine, Basham, & Sarason,
1983; Sarason et al., 1991). Moreover, the stress-buffering function of perceived social support in the health literature is
well recognized (Broadhead et al., 1983; Koopman et al., 2000; Terry, Rawle, & Callan, 1995).
According to attachment theory, attachment experiences shape social support perceptions, including perceptions of
the availability of others to provide support, and of the worthiness of the self to receive support (Bartholomew, Cobb, &
Poole, 1997). Specifically, secure individuals have been shown to perceive more potential providers of support
(Meyers & Landsberger, 2002; Sarason et al., 1991) and to be more satisfied with available support (Sarason et al.,
1991) than insecure individuals. Consistent with this view, Meredith, Strong and Feeney (submitted for publication)
demonstrated that secure attachment, high levels of comfort with closeness, and low levels of anxiety over
relationships, were each related to greater perceived concern of others, more supports, greater satisfaction with support,
and more support-seeking behavior, compared with insecure attachment.
Taken together, the evidence presented thus far suggests that appraisals of pain, self-efficacy, and social support
represent three cognitive factors that are empirically associated with both adult attachment pattern and chronic pain. If
insecure attachment is viewed as a diathesis for problematic adjustment to pain, then appraisals of the pain, self-efficacy,
and social perceptions associated with attachment insecurity may represent three mechanisms through which this
vulnerability might manifest.
5.1.2. Model Part C: responses to cognitive appraisals
In line with the work of Lazarus and Folkman (1984), the ADMoCP proposes that the appraisal process precedes the
selection of strategies for managing pain-related distress. In particular, if the appraisal process concludes that a stressor
is threatening, that one is unable to cope, and/or the environment is unsupportive, a range of cognitive, emotional and
behavioral reactions might ensue. According to attachment theory, such an appraisal will activate the attachment
system, selectively eliciting attachment-specific (1) emotions, (2) coping efforts and (3) support-seeking behavior.
These three variables are now briefly examined.
5.1.2.1. Coping strategies. Coping strategies have consistently been found to account for a large proportion of
variance in adjustment to chronic pain, including reported pain severity (Tan et al., 2001), quality of life (Echteld, van
Elderen, & van der Kamp, 2001; Raak et al., 2002), disability (Tan et al., 2001; Turner et al., 2000), and depression
(Tan et al., 2001). In particular, use of catastrophizing as a coping strategy by pain patients has been related to mental
health issues and physical incapacity (Raak et al., 2002; Turner et al., 2000).
In the attachment literature, securely attached individuals have been shown to adopt more diverse and effective
coping strategies than their insecure counterparts (Alexander, Feeney, Hohaus, & Noller, 2001; Feeney, 1999;
Feeney & Hohaus, 2001). Schmidt, Nachtigall et al. (2002) concluded that ambivalent (hyperactivating) individuals
show more maladaptive emotion-focused coping (e.g. wishing, catastrophizing), while avoidant (deactivating)
individuals utilize more denial and diverting strategies. Insecure attachment has been associated with the utilization of
more external strategies for self-regulation, including substance use, violence, and social isolation (Burk & Burkart,
2003), or promiscuity and alcohol abuse (Myers & Vetere, 2002).
421
Although Schmidt, Nachtigall et al. (2002) emphasized the broad applicability of attachment theory to coping processes,
to date there has been little consideration of the specific implications of attachment theory as it relates to coping with pain.
The only empirical evidence of a link between attachment theory and coping with pain was reported by Mikulincer and
Florian (1998), who cited unpublished data that insecure patients in chronic pain used more emotion-focused and less
problem-focused coping strategies to deal with their pain than patients with a secure attachment style. The associations
between attachment, catastrophizing (variously defined as a coping strategy or as a cognitive variable) and pain, have
received more attention, with empirical evidence consistently portrayed positive links between catastrophizing and anxious
attachment variables (Ciechanowski et al., 2003; McWilliams & Asmundson, 2007; Meredith et al., 2005, 2006b).
5.1.2.2. Support-seeking. Social support-seeking, a specific coping behavior, has received relatively little attention in
the pain literature. Weickgenant, Slater, Patterson, Atkinson, Grant and Garfin (1993) found that pain patients were
generally disinclined to seek social support (e.g., talk to someone, get professional advice) for an exacerbation of back
pain. Paulsen and Altmaier (1995) suggested, however, that patients displaying greater pain behaviors in the presence
of their spouses may be seeking support. Further, evidence from Mortimer, Ahlberg, and the MUSIC-Norrtalje study
group (2003) revealed that men and women reporting high pain and greater disability were more likely to seek care
from health professionals and other supports than those reporting lower pain and disability.
Support-seeking has been described as an attachment-related coping behavior that may be elicited at times of
distress and alleviated by the presence of a supportive other (Bartholomew et al., 1997; Kolb, 1982; Mikail et al.,
1994). According to attachment theory, just as attachment figures provide a secure base and safe haven in times of
distress in childhood, so the social network fulfills this role in adulthood. Feeney and Kirkpatrick (1996) highlighted
the tendency for securely attached individuals to seek care and social support when distressed, and for less secure
individuals to vary in their tendency to seek support. In the context of chronic pain, Meredith et al. (submitted for
publication) demonstrated that individuals reporting secure attachment, high levels of comfort with closeness, or low
levels of anxiety over relationships, each reported more support-seeking behavior than their less secure counterparts.
5.1.2.3. Emotional state. According to cognitive theory, cognitive processes are a key causal aspect of the emotional
response (Lazarus, 1993; Lazarus et al., 1980). A substantial body of evidence also links negative emotions, including
anger, fear, anxiety, and depression, with pain disorders (Ericsson et al., 2002; Gamsa & Vikis-Freibergs, 1991;
Simpson, Rholes, & Nelligan, 1992). In support of a diathesisstress model of chronic pain, Pinkus and Williams
(1999) suggested that there may be enduring information processing biases that, when combined with a stressor such as
chronic pain, result in negative mood states.
Evidence linking insecure attachment patterns with problematic affect regulation is extensive. Simpson et al. (1992)
stated that attachment styles primarily serve to regulate how individuals interpret, understand, and cope with
negative emotional experiences during stressful situations (p. 443). Anxious attachment has been more consistently
associated with negative affect than has avoidant attachment. In the context of unremitting pain, however, it is possible
that the evoked dependency and limitations to physical work and recreational activities (Anderson & Hines, 1994)
challenges the preferred coping strategies of avoidant individuals, increasing the likelihood of subsequent distress. The
literature in the attachment/pain field supports these expectations, with both avoidant and anxiously attached
individuals in chronic pain reporting increased psychological distress (Mikulincer & Florian, 1998; Pearce et al., 2001),
pre- and post-treatment depression (Ciechanowski et al., 2003; Meredith et al., 2005, 2007), anxiety and stress
(Meredith et al., 2005, 2006a), and pain-related fear (McWilliams & Asmundson, 2007; Schmidt, Nachtigall et al.,
2002) compared to individuals with secure attachment. Although pain-related fear and anxiety are well recognized in
the pain field, it is noteworthy that there is, to date, limited empirical evidence linking attachment theory to either of
these pain variables. In addition, both the anxiety over relationships dimension and dismissing attachment variable
were linked with depression in laboratory pain investigations (Meredith et al., 2006b).
5.1.3. Model Part D: impact on adjustment
Measures of adjustment to pain, or treatment outcome, utilized in pain-related literature are diverse and include
measures of: pain behavior, self-reported pain severity, activity level, physical strength, mobility, social functioning,
activities of daily living, medication use, health/professional services utilization, employment status, and psychological
functioning such as morale, depression, anxiety (Jensen, Turner, Romano, & Karoly, 1991; Meana, 1998). This
extensive range of variables complicates the conduct and interpretation of pain outcome research, with further
422
challenges evident in the dual use of predictor variables (such as mood or distress) as outcome measures. Nevertheless,
regardless of the outcome measure employed, negative appraisals, maladaptive coping strategies, and negative
emotional states are widely accepted as vulnerabilities to problematic adjustment to pain.
Despite the relatively consistent findings concerning associations between attachment variables (A) and both the
cognitive appraisal variables (B) and reaction variables (C), the literature revealed that attachment variables were
frequently not, themselves, significant predictors of outcome measures such as pain intensity, severity or disability (e.g.
Ciechanowski et al., 2003; Meredith et al., 2005, 2006a; Pearce et al., 2001). As previously noted, these findings vary
from other evidence in the field (McWilliams et al., 2000; Rossi et al., 2005). For example, Rossi et al. (2005) identified
that insecure attachment was the most significant predictor of disability for those with episodic migraine. These
inconsistent findings may be related to the differences in pain populations, measurement approaches, methodologies,
and cultural context, and thus clarification is needed through systematic research.
5.1.4. Mediation/moderation
According to the ADMoCP, the relationships between pain outcome variables (D) and the following variables: (a)
appraisal of pain, (b) self-efficacy, (c) perceived social support, (d) coping, (e) support-seeking, and (f) emotional state,
would be mediated and/or moderated by the attachment dimensions (for the distinction between mediation and
moderation see Baron & Kenny, 1986).
There is some evidence that attachment variables moderate and/or mediate the associations between many of the
appraisals and responses indicated in the ADMoCP, and pain intensity and disability. MacDonald and Kingsbury
(2006) found that anxious attachment mediated the relationship between anxiety and pain affect (incorporating pain
intensity), and partially mediated the relationship between depression and pain affect. In Meredith et al.'s (2006b)
laboratory investigation of a pain-free sample, the continuous measure of secure attachment was shown to moderate the
association between catastrophizing and pain intensity, such that less secure individuals were more likely to
catastrophize in response to higher pain intensity.
In the Meredith et al. (2006a, 2007, submitted for publication) studies, comfort with closeness was found to be the
main moderator of associations between psychosocial variables and pain variables (pain intensity/disability) in a
chronic pain sample. In addition, Meredith et al. (2005) reported on a range of mediation analyses that demonstrated
that threat appraisal mediated the relationship between attachment anxiety and stress, and partially mediated the
relationships between attachment anxiety and depression, and attachment anxiety and catastrophizing. This finding is
consistent with the ADMoCP, in which the appraisals (B) are positioned between the attachment (A) and response (C)
variables. Taken together, these moderating and mediating relationships highlight the interactive mechanisms by which
insecure attachment affects the experience of chronic pain.
Thus, a small body of evidence has suggested that both moderational and mediational associations exist among
the variables included in the ADMoCP. In the absence of more extensive and rigorous empirical evidence
addressing the specific nature of the associations (e.g., path analyses), the model has been intentionally constructed
as a broad framework. In this way, it avoids being too prescriptive about the specific nature and direction of these
relationships.
Overall, emerging empirical evidence supports the application of adult attachment theory to the field of chronic
pain. These findings, in turn, have supported the ADMoCP as a preliminary model of the psychosocial mechanisms
underlying chronic pain.
6. Implications for intervention
The recognition that insecure attachment can be an obstacle to successful treatment in some clinical settings (Burk &
Burkart, 2003; Dozier, 1990) highlights the value of employing an attachment perspective to improve clinical
management for those with chronic pain. Based on this review, adult attachment theory warrants further consideration
in relation to treatment, early intervention, and prevention of chronic pain conditions.
6.1. Prevention
Projects aimed at supporting the development of a secure attachment pattern in infancy, or increasing attachment
security prior to the development of chronic pain, are representative of prevention efforts. For example, Hoffman and
423
colleagues (Cassidy et al., 2005; Cooper, Hoffman, Powell, & Marvin, 2005; Marvin, Cooper, Hoffman, & Powell,
2002) conceptualized The Circle of Security Project, which has gained world-wide recognition as a brief approach to
improving infant and child attachment security.
6.2. Early intervention and treatment
Integration of chronic pain and attachment theory may have several advantages in terms of early intervention and
treatment, including: a) identifying individuals at risk of developing chronic pain following episodes of acute pain,
b) identifying individuals at risk of adjustment difficulties to chronic pain prior to treatment, c) tailoring treatment
protocols for these individuals based on an attachment-informed understanding of their needs, and d) guiding ongoing
intervention for these individuals at the completion of a standard rehabilitation program.
In addition, it is possible, through a variety of treatment approaches, to increase attachment security. Strategies
include the provision of a secure base of support, use of secure-base priming techniques (Mikulincer & Arad, 1999;
Mikulincer & Shaver, 2001), and relationship-based or emotion-focused psychotherapeutic approaches (Dallos, 2004;
Goodwin, 2003; Sonkin & Dutton, 2003). Brief psychotherapeutic attachment-informed interventions have been
described (e.g., BABI, Holmes, 2001), and have also been adapted for use with medically unexplained symptoms
(Maunder & Hunter, 2004). These authors have developed a brief, integrated attachment and existential psychology
approach titled Meaning- and Attachment-Based Intervention (Maunder & Hunter, 2004) which might be usefully
incorporated into pain treatment programs. The application and evaluation of these clinical interventions constitutes
one of the most promising areas of research in this field.
7. Further research
The field of attachment theory and chronic pain is a fertile ground for further research. There is broad scope to
replicate earlier studies with attention to methodological concerns, as well as to address a range of new questions. For
example, further studies might consider: (a) employing samples drawn from a wider range of facilities and from the
general community, (b) differentiating between medically explained and medically unexplained pain, (c) controlling
for medical diagnoses, (d) using the Adult Attachment Interview to measure attachment, (e) including a measure of
social desirability bias, (f) employing more objective measures of functional outcome, and (g) incorporating reports
from significant others. Further research is also needed to consider longer-term implications of adult attachment
security for adjustment to pain, and implications of attachment pattern for outcome from pain treatment programs.
Based on the evidence reviewed, the ADMoCP is proposed as a useful framework for further research.
In addition, Meredith et al. (2006b) contended that attachment anxiety, as a diathesis for maladaptive appraisals and
responses to acute pain might, in turn, lead to an increased likelihood of developing chronic pain syndromes, and to
problematic responses to chronic pain experiences. This latter question remains to be addressed with longitudinal
studies of pain-free individuals. The comprehensive associations between attachment and psychosocial variables in the
context of chronic pain have key implications for treatment. In particular, the prospect of strengthening or
complementing present chronic pain rehabilitation protocols with attachment-informed therapeutic approaches merits
systematic investigation.
8. Summary and conclusions
Despite the established efficacy of a range of clinical approaches for chronic pain, it is recognized that present
approaches still fail to assist a significant proportion of individuals (Turk, 1990, 2005). Adult attachment theory has
been proposed as an effective developmental model for the chronic pain condition (Anderson & Hines, 1994; Kolb,
1982; Mikail et al., 1994). In this review we have drawn on recent theoretical perspectives and empirical evidence in
proposing an integrative model, the Attachment-Diathesis Model of Chronic Pain (ADMoCP), in which attachment
insecurity represents a diathesis (or pre-disposition) for developing chronic pain and associated disability. Specifically,
the ADMoCP portrays adult attachment as (a) predictive of psychosocial variables known to be associated with the
onset and maintenance of pain, (b) moderating the association between these psychosocial variables and both pain
intensity and disability, and, in some cases (c) predictive of variables that reflect adjustment to pain, such as perceptions
of pain intensity and pain-related disability. Thus, according to the ADMoCP, an insecure adult attachment pattern
424
represents both a risk factor for the development of chronic pain, and a vulnerability factor for poor outcome in the face
of chronic pain (see Rose, Holmbeck, Coakley, & Franks, 2004, for definitions of risk and vulnerability factors).
Evidence from the present review supports associations between insecure attachment and a range of maladaptive
psychosocial variables for those in chronic pain, including: (a) perceptions of pain as more threatening, (b) more
negative perceptions of the availability and adequacy of social support, (c) lower pain self-efficacy, (d) less supportseeking, (e) more stress, depression and anxiety, (f) an increased tendency to catastrophize, and (g) less adaptive coping
strategies. These findings support the Attachment-Diathesis Model of Chronic Pain (ADMoCP). The comprehensive
associations between attachment and psychosocial variables in the context of chronic pain now warrant consideration
in terms of implications for treatment.
Acknowledgements
The authors gratefully acknowledge the financial support of the Graduate School, the School of Health and
Rehabilitation Sciences, and the Division of Occupational Therapy at The University of Queensland. The contribution
of Associate Professor Judith Feeney to early work by this group has also been greatly appreciated.
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Clinical Psychology Review 28 (2008) 407 429

A review of the evidence linking adult attachment theory and chronic

P. Meredith et al. / Clinical Psychology Review 28 (2008) 407429

A review of the literature linking adult attachment theory and pain

P. Meredith et al. / Clinical Psychology Review 28 (2008) 407429

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4.1. Studies employing an attachment framework to explain pain

Chronic pain and psychosocial variables Main outcomes

Attachment Self-Report (ASR,

Mental Health Inventory (Veit &

Attachment Self-Report (ASR,

Revised Adult Attachment Scale

Revised Adult Attachment Scale

Extent of pain one question.

Avoidant and anxious-ambivalent men

The analysis identified 54 secure, and 146

P. Meredith et al. / Clinical Psychology Review 28 (2008) 407429

Relationship Scale Questionnaire

Attachment Style Questionnaire

Catastrophizing subscale of the

Fearful attachment was associated with

Overall, disability was associated with

Secure attachment linked with challenge

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Chronic pain and psychosocial variables Main outcomes

Relationship Questionnaire (RQ,

Relationship Questionnaire (RQ,

In response to experimental coldpressor

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associations: (1) pain self-efficacy and

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5.1. The Attachment-Diathesis Model of Chronic Pain

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