Pain 127 (2007) 2734

www.elsevier.com/locate/pain

The relationship of adult attachment dimensions to pain-related fear,

hypervigilance, and catastrophizing
a,* b
Lachlan A. McWilliams , Gordon J.G. Asmundson
a
Department of Psychology, Acadia University, Wolfville, NS, Canada B4P 2R6
b
Faculty of Kinesiology and Health Studies, University of Regina, Canada

Received 29 December 2005; received in revised form 7 July 2006; accepted 7 July 2006

Abstract

Despite the prominence of fear-avoidance models of chronic pain, there is a paucity of research regarding the origins of pain-
related fear. Based on the premise that insecure attachment could be a developmentally based origin of elevated fear of pain, asso-
ciations between adult attachment dimensions and constructs included in fear-avoidance models of chronic pain were investigated.
Consistent with Bartholomew and Horowitzs [Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a
four-category model. J Pers Soc Psychol 1991;61:22644.] model, attachment was conceptualized as being comprised of a model of
self dimension (i.e., degree of anxiety regarding rejection based on beliefs of personal unworthiness) and a model of others dimen-
sion (i.e., degree of interpersonal mistrust and discomfort with interpersonal closeness). A large university student sample free of
chronic pain (N = 278) completed a measure of adult romantic attachment (i.e., Experiences in Close Relationships Questionnaire;
[Brennan KA, Clark CL, Shaver PR. Self-report measurement of adult attachment: an integrative overview. In: Simpson JA, Rholes
WS, editors. Attachment theory and close relationships. New York: The Guilford Press, 1998. p. 4676.]), the Fear of Pain Ques-
tionnaire-III [McNeil DW, Rainwater AJ. Development of the fear of pain questionnaire III. J Behav Med 1998;21:389410.], the
Pain Vigilance and Awareness Questionnaire [McCracken LM. Attention to pain in persons with chronic pain: a behavioural
approach. Behav Ther 1997;28:27184.], and the Pain Catastrophizing Scale [Sullivan MJ, Bishop SR, Pivik J. The pain catastro-
phizing scale: development and validation. Psychol Assess 1995;7:24532.]. It was hypothesized that insecure attachment would be
positively associated with reports of pain-related fear, hypervigilance, and catastrophizing and that the model of self dimension
would be the attachment variable most strongly associated with these variables. Correlation and multiple regression analyses
supported these hypotheses. The model of self dimension had signicant positive associations with each of the fear-avoidance
constructs. The model of others dimension had a signicant positive association with pain catastrophizing, but was not signicantly
associated with fear of pain and pain hypervigilance. Future research directions and potential clinical implications are discussed.
2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Keywords: Fear-avoidance models; Fear of pain; Catastrophizing; Adult attachment

1. Introduction disability (Asmundson et al., 2004a). However, there has

been little research regarding the origins of pain-related
Many studies have supported the notion that pain-re- fear. Attachment theory (Bowlby, 1969) has been pro-
lated anxiety and fear lead to chronic pain and increased posed as a framework for understanding the develop-
ment of chronic pain. Given that attachment theory
suggests attachment insecurity is associated with exag-
* gerated negative appraisals, insecure attachment holds
Corresponding author. Tel.: +1 902 585 1495; fax: +1 902 585
1078. promise as a developmentally based origin of elevated
E-mail address: Lachlan.Mcwilliams@acadiau.ca (L.A. McWilliams). fear of pain.

0304-3959/$32.00 2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.pain.2006.07.020
28 L.A. McWilliams, G.J.G. Asmundson / Pain 127 (2007) 2734
Bartholomew and Horowitzs (1991) inuential mod-
el posits that adult attachment styles are based on two
orthogonally related dimensions. Model of self refers
to the attachment dimension that can range from an
internalized sense of self-worth to anxiety regarding
rejection based on beliefs of personal unworthiness.
Model of others refers to a dimension ranging from trust
and comfort with intimacy to mistrust and avoidance of
close relationships. Each model can be dichotomized to
yield four unique attachment styles, including one that is
secure (i.e., positive models of self and others) and three
that are insecure (i.e., preoccupied: negative self/positive
others; fearful: negative self/negative others; dismissing:
positive self/negative others).
Recent research regarding the potential role of inse-
cure attachment in chronic pain has focused on the pos-
sibility that those with insecure attachment make more
negative appraisals of pain. For example, in a chronic
pain sample, Meredith et al. (2005) found that attach-
ment anxiety (similar to a negative model of self) was
positively associated with a measure assessing appraisals
of pain as threatening. They also found comfort with
closeness (similar to positive model of others) to be pos-
itively associated with more adaptive appraisals (i.e.,
seeing pain as a challenge). Positive associations
between attachment variables and pain catastrophizing
have also been found (Ciechanowski et al., 2003;
Meredith et al., 2006).
Based on the premise that insecure attachment could
be a developmentally based origin of elevated levels of
fear of pain, the present study was designed to evaluate
relationships between adult attachment dimensions and
individual dierence variables included in contemporary
fear-avoidance models of chronic pain (see Vlaeyen and
Linton, 2000) fear of pain, hypervigilance, and catas-
trophizing. A sample free of chronic pain was utilized
in order to determine whether relationships between
adult attachment and pain-related variables exist prior
to development of chronic pain. In general, it was
hypothesized that those with more negative models of
self and others would report greater levels of pain-relat-
ed fear, hypervigilance, and catastrophizing. Based on
Bartholomew et al.s (1997) suggestion that sensitivity
to potential threat is characteristic of those with nega-
tive models of self, it was hypothesized that the model
of self dimension would have relatively strong associa-
tions with the fear-avoidance variables. Based on
research regarding attachment and another fear con-
struct (viz., anxiety sensitivity; e.g., Watt et al., 2005),
it was expected that the model of others dimension
would have relatively weak associations with the fear-
avoidance variables. Grin and Bartholomew (1994)
demonstrated that relationships between attachment
dimensions and dependent variables may be moderated
by the other attachment dimension, so interaction eects
were also tested.
2. Method
2.1. Participants and procedure
Participants were recruited from the University of Manito-
bas Department of Psychology subject pool after the study
had received approval from the Psychology/Sociology
Research Ethics Board. Potential participants were informed
that the study was aimed at understanding relationship styles
and pain-related behaviors. Individuals interested in partici-
pating were asked to attend one of several data collection ses-
sions. Those willing to participate were asked to provide
informed written consent and then completed a questionnaire
package. All participants received course credit for an intro-
ductory psychology course as compensation for their eorts.
A total of 308 individuals participated in the study. In order
to ensure the sample was comprised only of those free of
chronic or persistent pain, a series of questions (see below)
were used to identify those experiencing such pain. When this
procedure was applied, 30 participants (9 males and 21
females) were classied as having chronic pain. The remaining
participants were free of chronic pain (N = 278), had an aver-
age age of 20.22 (SD = 3.97) years, were primarily single
(92.8%), and were almost equally distributed with regard to
gender (145 males and 136 females). A majority of participants
reported being Caucasian (63.3%), but the sample also includ-
ed those identifying themselves as Asian (19.8%), Native (or
Canadian Aboriginal) (4.7%), or Black (2.2%). A small num-
ber of participants endorsed the Other category (7.6%), and
a few did not provide a response regarding their racial or eth-
nic background (2.5%). The chronic pain group was slightly
older (M = 22.40, SD = 7.19) than the study sample, but this
dierence was only marginally signicant [t(30.94) = 1.78,
p = .08 (2-tailed test)]. A chi-square analysis indicated that
there was a disproportionate number of females in the chronic
pain group [v2(1) = 4.98, p = .02 (2-tailed test)]. The study
sample did not signicantly dier from the chronic pain group
on the attachment or pain appraisal variables. The chronic
pain group was not included in any of the subsequent analyses.
2.2. Measures
A brief demographics questionnaire was used to obtain
information from the participants regarding their age, gender,
marital status, and ethnic/racial background. Several questions
concerning ongoing pain and pain history were included in
order to determine whether the respondents should be consid-
ered as having chronic or persistent pain. They were asked to
indicate whether they currently had pain or discomfort that
has persisted continuously or intermittently for longer than
three months? This method was adapted from the method
utilized in Elliott et al.s (1999) epidemiological study of chron-
ic pain. Those indicating the presence of such pain were asked
a series of follow-up questions regarding the frequency of their
pain, the intensity of their pain, and physician contact regard-
ing the pain. The pain intensity rating was based on the present
pain intensity rating method used in the McGill Pain Question-
naire (Melzack, 1975) and ranged from 0 (No pain) to 5
(Excruciating). Individuals were considered to have chronic
or persistent pain if they (a) reported the presence of continu-
ous or intermittent pain over the past 3 months, (b) indicated
 L.A. McWilliams, G.J.G. Asmundson / Pain 127 (2007) 2734
that the pain occurred almost everyday or more, (c) rated the
pain intensity as discomforting or worse, and (d) reported con-
sulting with a physician regarding this pain.
The Experiences in Close Relationships Questionnaire
(ECR; Brennan et al., 1998) includes an 18-item Model of Self
scale and an 18-item Model of Others scale (also commonly
referred to as Anxiety and Avoidance scales, respectively).
Respondents are asked to indicate their level of agreement with
a series of statements concerning their romantic relationship
experiences using a response format ranging from 1 (Disagree
strongly) to 7 (Agree strongly). Scale scores are created by tak-
ing the average score of the items from each scale. Higher
scores indicate more negative models. The ECR was developed
based on a series of analyses (i.e., factor analytic and correla-
tional) designed to select items from existing attachment mea-
sures that best capture the two attachment dimensions.
Brennan et al. (1998) reported a-coecients > .90 for each of
these scales and reported several analyses supportive of their
construct validity. A recent item response theory analysis of
several commonly used measures of adult attachment indicat-
ed that the ECR scales showed the greatest degree of measure-
ment precision (Fraley et al., 2000). Throughout this paper, the
terms Model of Self and Model of Others (capitalized) are used
to refer to the ECR scales whereas the terms model of self and
model of others (not capitalized) are used to refer to the attach-
ment constructs operationalized by the ECR.
The Fear of Pain Questionnaire-III (FPQ-III; McNeil and
Rainwater, 1998) is a 30-item self-report measure of fear of
pain. This measure presents a series of hypothetical painful sit-
uations (e.g., breaking ones arm) and requires the respondent
to rate the degree of fear they anticipate experiencing related to
the painful event. A Likert scale ranging from 1 (Not at all) to 5
(Extreme) is used. The FPQ-III is comprised of three subscales
assessing Fear of Severe Pain (e.g., Being in an automobile
accident), Fear of Minor Pain (e.g., Biting your tongue while
eating), and Fear of Medical Pain (e.g., Having a blood sam-
ple drawn with a hypodermic needle). The total FPQ-III score
is obtained by summing the responses to each item. McNeil and
Rainwater (1998) reported that the FPQ-III has excellent inter-
nal consistency (i.e., a = .92), adequate testretest reliability
(i.e., .74) over a 3-week period, and good construct validity.
The Pain Vigilance and Awareness Questionnaire (PVAQ;
McCracken, 1997) is a 16-item measure of attention to pain.
The original PVAQ was designed for use with chronic pain
patients and requires respondents to consider their behavior
over the last 2 weeks and to indicate how frequently each item
is true using a scale ranging from 0 (Never) to 5 (Always).
McCracken (1997) reported ndings supportive of its internal
consistency, testretest reliability, and construct validity. More
recently, Roelofs et al. (2002) provided evidence supportive of
its convergent and divergent validity. They found PVAQ
scores were highly correlated with measures of related con-
structs, such as catastrophizing, and weakly correlated with
measures of unrelated constructs, such as trait anxiety. A
slightly modied version of the PVAQ suitable for use with
non-clinical samples was used. McWilliams and Asmundson
(2001) reported that this modied version of the PVAQ has
excellent internal consistency (a = .92) and that its correlations
with pain-related variables (e.g., pain severity ratings and pain-
related restriction in activities) were supportive of its construct
validity.
29
The Pain Catastrophizing Scale (PCS; Sullivan et al., 1995)
is a 13-item self-report measure designed to assess catastrophic
thoughts or feelings accompanying the experience of pain.
Respondents are asked to reect on past painful experiences
and to indicate the degree to which each of the 13 thoughts
or feelings are experienced when in pain. The questionnaire
uses a 5-point scale ranging from 0 (Not at all) to 4 (All the
time). The PCS has been found to be reliable (i.e., a = .95;
Osman et al., 2000) and to have a testretest reliability of .70
when readministered over periods ranging from 8 to 12 weeks
(Sullivan et al., 1995). Supportive of its construct validity, PCS
scores have been found to be positively associated with cata-
strophic thoughts in response to an experimental pain proce-
dure (i.e., the cold pressor) and to contribute signicant and
unique variance to the prediction of pain intensity during such
procedures (Sullivan et al., 1995).
3. Results
All statistical analyses were conducted with the Sta-
tistical Package for the Social Sciences (version 14.0
for Windows). In order to determine whether the data
conformed to the assumptions of the statistical tests
used, the KolmogorovSmirnov test was used to deter-
mine whether the data deviated from the normal distri-
bution. Most variables did not signicantly deviate from
the normal distribution (KolmogorovSmirnov Z values
in parentheses) including the Model of Self (0.63), the
FPQ-III (0.91), the PVAQ (1.18), and the PCS (1.10).
The distribution of Model of Others scores did signi-
cantly dier from the normal distribution (1.39,
p = .04) as did age (4.69, p < .001). Both of these
variables were positively skewed (skewness of Model
of Others = 0.37, skewness of age = 3.38). The Model
of Others variable became normally distributed after a
square root transformation was applied (Kolmogorov
Smirnov Z = 1.16, n.s.; skewness = 0.03). Age could
not be successfully transformed, so it was dichotomized
using a median split. Analyses using the transformed
Model of Others variable and the dichotomous age
variable did not dier substantially from those
performed on the non-transformed variables, so the
non-transformed results are presented.
Descriptive statistics for each of the self-report mea-
sures are presented in Table 1 along with their internal
consistency coecients and their inter-correlations
(2-tailed statistical tests were used for all correlation
and regression analyses). From this table it can be seen
that each measure had an acceptable level of internal
consistency. The preliminary correlational analyses
revealed that: (a) the two attachment scales did not over-
lap or share signicant variance with each other, (b) the
pain-related measures all shared common variance, (c)
Model of Self was positively associated with each of
the pain-related measures, and (d) Model of Others
had a signicant positive association with the PCS,
but was not signicantly associated with other two
30 L.A. McWilliams, G.J.G. Asmundson / Pain 127 (2007) 2734

Table 1
Self-report measure descriptive statistics and correlations (N = 278)
Measure Cronbachs a Mean SD Correlations
1 2 3 4 5
1. Model of Self .90 3.27 1.11 .08 .18** .21*** .26***
2. Model of Others .91 2.87 1.07 .03 .03 .14*
3. FPQ-III .93 76.78 20.28 .30*** .34***
4. PVAQ .75 36.16 14.58 .38***
5. PCS .88 15.70 9.01
Note. Model of Self and Model of Others are from the Experiences in Close Relationships Questionnaire. FPQ-III, Fear of Pain Questionnaire III;
PVAQ, Pain Vigilance and Awareness Questionnaire; PCS, Pain Catastrophizing Scale.
*
p 6 .05.
**
p 6 .01.
***
p 6 .001 (2-tailed tests).

pain-related variables. In these correlation analyses, and (1, 272) = 0.39, n.s.] or PCS [F Change (1, 272) = 2.46,
in the regression analyses reported below, ndings using n.s.] scores. However, the addition of Step 2 did signi-
the FPQ-III subscales were similar to those obtained cantly improve the statistical model predicting PVAQ
with total FPQ-III scores, so only those regarding the scores [Change F(1, 272) = 6.67, p = .01]. The adjusted
later are reported. R2 value from this model indicated that the inclusion
There were no specic hypotheses regarding potential of the interaction term accounted for an additional
moderation eects. However, Grin and Bartholomew 1.9% of the variance in PVAQ scores. The standardized
(1994) noted that it is important to consider the combi- b values from Step 2 of these models are also reported in
nation of the two attachment dimensions and demon- Table 2. From this table it can be seen that the interac-
strated that the relationships between attachment tion variable had a signicant positive association with
dimensions and dependent variables may be moderated the PVAQ. To interpret this signicant interaction
by the other attachment dimension. Hierarchical multi- eect, a median split was used to divide the sample into
ple linear regressions were used to test whether the two a group comprised of those with a relatively negative
attachment dimensions interacted in the prediction of model of others (i.e., those with scores above the median
the dependent variables. These analyses involved two on the Model of Others scale) and a group comprised of
steps. In Step 1, the demographic variables (viz., age those with a relatively positive models of others (i.e.,
and gender) and the two ECR scales were entered. In those with scores below the median on the Model of
Step 2, the interaction term was entered. Following Others scale). Correlations between Model of Self and
Aiken and Wests (1991) recommendations for testing
interaction eects, the ECR scales were centered (i.e.,
put in deviation score form with means of zero) and Table 2
Standardized b values in the hierarchical linear regression models
the interaction term (a variable created by multiplying
the two ECR scales) was formed using the centered ver- Independent variables Dependent variables
sions of the ECR scales. FPQ-III PVAQ PCS
The regression models in Step 1 were statistically sig- Step 1
nicant when the FPQ-III [F(4, 273) = 12.18, p < .001], Age .08 .07 .09
PVAQ [F(4, 273) = 4.26, p = .002], and the PCS Gender .33*** .11 .18**
Model of Self .22*** .21*** .25***
[F(4, 273) = 8.49, p < .001] were included as dependent Model of Others .03 .02 .13*
variables. Respectively, the adjusted R2 values indicated
Step 2
that the nal models accounted for 13.9%, 4.5%, and
Age .08 .06 .10
9.8% of the variance in FPQ-III, PVAQ, and PCS Gender .33*** .11 .18**
scores. The standardized b values from these models Model of Self .21*** .22*** .26***
are reported in Table 2. They indicate that participants Model of Others .03 .03 .14*
with an insecure model of self reported higher levels of Interaction (model of Self
by model of Others) .04 .15** .09
pain-related fear, hypervigilance, and catastrophizing.
The Model of Others dimension of attachment had a Note. Model of Self and model of Others are from the Experiences in
signicant positive association with PCS scores, but Close Relationships Questionnaire. FPQ-III, Fear of Pain Question-
naire III; PVAQ, Pain Vigilance and Awareness Questionnaire; PCS,
was not signicantly associated with the other pain-re- Pain Catastrophizing Scale.
lated measures. *
p 6 .05.
The addition of Step 2 did not signicantly improve **
p 6 .01.
***
the statistical models predicting FPQ-III [F Change p 6 .001 (2-tailed tests).
 L.A. McWilliams, G.J.G. Asmundson / Pain 127 (2007) 2734
PVAQ scores were examined in these two groups. The
correlation coecients indicated that there was a signif-
icant positive association between Model of Self and
PVAQ scores amongst those with negative models of
others [r(137) = .36, p < .001] and that there was no sta-
tistically signicant association between Model of Self
and PVAQ scores amongst those with positive models
of others [r(137) = .04, n.s.].
Fraley and Waller (1998) reported a taxometric anal-
ysis that indicated model of self and model of others are
most appropriately conceptualized as continuous
dimensions [i.e., people vary in degrees along these
dimensions rather than possessing qualitatively dierent
working models (e.g., insecure models of self versus
positive models of self)]. Nonetheless, they also noted
that the use of attachment taxons, or categories, may
more accurately reect how attachment is typically con-
ceptualized. In order to further explore the interaction
eect obtained with the PVAQ in a manner consistent
with this more intuitively appealing approach, dierenc-
es between the attachment categories were considered.
Utilizing classication coecients derived from a linear
discriminant functions analysis conducted on a large
university sample (N = 1082), Brennan et al. (1998)
developed a method to assign individuals to one of the
attachment categories based on their scores on the two
attachment scales. This procedure classies individuals
into one of four possible categories in Bartholomews
model. In the present sample, the majority of partici-
pants (n = 107) were classied as having secure attach-
ment. The other participants were approximately
equally distributed across the fearful (n = 58), preoccu-
pied (n = 56), and dismissing (n = 57) attachment
categories.
If the ndings of the correlation and regression anal-
yses regarding the PVAQ were extrapolated to a cate-
gorical conceptualization of attachment, those with
fearful attachment (i.e., negative models of others and
negative models of self) would be expected to be more
vigilant to pain than those with dismissing attachment
(i.e., negative models of others and positive models of
self). It would also be expected that those with dismiss-
ing, preoccupied (i.e., negative models of self and posi-
tive model of others) and secure (i.e., positive models
of self and others) attachment would not signicantly
dier with regard to PVAQ scores. An analysis of vari-
ance (ANOVA) indicated a trend eect for attachment
category [F(3, 274) = 2.437, p = .065]. As expected, post
hoc analyses (with Bonferroni corrections) indicated
that the PVAQ scores of those with dismissing attach-
ment (M = 32.39, SD = 14.24) were lower than those
with fearful attachment (M = 39.53, SD = 18.45), but
this dierence was only marginally signicant
(p = .051). Given the loss of statistical power that results
from dichotomizing continuous variables, this failure to
obtain a highly signicant nding is not surprising. Also
31
as expected, the PVAQ scores of the secure (M = 35.86,
SD = 13.38) and preoccupied (M = 37.10, SD = 11.77)
groups did not dier signicantly from each other or
from those of the other attachment categories. The
examination of PVAQ scores across attachment catego-
ries was used to further interpret the interaction eect
obtained with the PVAQ. Since signicant interaction
eects were not found with regard to the FPQ-III and
the PCS, group comparisons were not made regarding
these variables.
4. Discussion
Based on the premise that insecure attachment
could be a developmentally based origin of elevated
fear of pain, the present study investigated associations
between adult romantic attachment variables and a
range of specic constructs included in contemporary
fear-avoidance models of chronic pain. It was hypoth-
esized that the ECR Model of Self scale would be pos-
itively associated with reports of pain-related fear,
hypervigilance, and catastrophizing. It was also expect-
ed that the ECR Model of Others scale would be only
weakly associated with these fear-avoidance variables.
Both of these hypotheses were supported as the ECR
Model of Self scale had signicant positive correlations
with the FPQ-III, PVAQ, and the PCS. In contrast,
the ECR Model of Others scale had a signicant posi-
tive relationship with the PCS, but had only small non-
signicant associations with the FPQ-III and the
PVAQ.
In the present study, those with negative models of
self reported greater levels of pain-related fear, hypervig-
ilance, and catastrophizing than those with more posi-
tive models of self. Application of attachment theory
to the context of pain would suggest that those with neg-
ative models of self view themselves as less capable of
coping with pain and/or view themselves as unworthy
of assistance from others during an episode of pain.
The nding that model of others was signicantly asso-
ciated with only catastrophizing was not anticipated.
However, Sullivan et al.s (2001) communal coping
model of pain-related catastrophizing may provide a
framework for understanding this nding. This model
suggests that catastrophizing is a means of communicat-
ing distress and eliciting social support. Individual dif-
ference variables related to this form of coping have
not yet been identied. The present ndings suggest that
attachment variables may be related to the communal/
catastrophizing form of coping described by Sullivan
et al. Of particular relevance to contextualizing the pres-
ent ndings, it may be that those who perceive others as
generally unwilling to provide support may exaggerate
their distress in order to obtain the assistance of others.
It is noteworthy that this type of relationship bears a
striking resemblance to Kolbs (1982) observation that
32 L.A. McWilliams, G.J.G. Asmundson / Pain 127 (2007) 2734
patients complaints of pain are often attachment behav-
iors designed to elicit caretaking behavior in others.
Grin and Bartholomew (1994) indicated that rela-
tionships between attachment dimensions and depen-
dent variables may be moderated by the other
attachment dimension. To explore this possibility mul-
tiple regression analyses were used to test for interac-
tion eects involving the two attachment dimensions.
Only in the case of pain hypervigilance was the inter-
action term a statistically signicant predictor. To
interpret this signicant interaction eect, two subsam-
ples dened by either a relatively negative model of
others or a relatively positive model of others were
created and the correlation between model of self
and hypervigilance was calculated within each group.
The pattern of ndings revealed a moderation eect
in which there was a statistically signicant positive
relationship between model of self and hypervigilance
that was only present amongst those with negative
models of others.
PVAQ scores have been shown to be signicantly
associated with FPQ-III and PCS scores (Roelofs
et al., 2003, 2002) and in the present study scores
on each of these measures were signicantly correlated
with each other. Given this shared variance between
the fear-avoidance variables, it is surprising that a sig-
nicant interaction eect was found with regard to the
PVAQ but not the other pain measures. The rst fol-
low-up analyses used to interpret the interaction eect
(correlations in negative and positive model of others
subsamples) indicated that the combination of a nega-
tive model of others and positive model of self (i.e.,
dismissing attachment) was associated with the lowest
scores on the PVAQ. The second follow-up analyses
(between group comparisons) were consistent with
this, but the ndings were not statistically signicant.
It has been suggested (Bartholomew et al., 1997) that
those with dismissing attachment defensively exclude
distress from their awareness. The relatively low scores
on the PVAQ of those with a dismissing attachment
style may reect one way in which this tendency is
manifested. When considered across dependent vari-
ables the pattern of ndings is consistent with the
notion that those with dismissing attachment tend to
suppress their awareness of pain, but once pain is
experienced they do not dier from other individuals
with negative models of others (i.e., the fearful attach-
ment group) in terms of their fearfulness and
catastrophizing.
While the cross-sectional nature of the study limits
causal conclusions from being drawn, the ndings sug-
gest that insecure attachment could be a developmen-
tally based origin of elevated fear of pain. In
conjunction with earlier ndings with chronic pain
patients (Ciechanowski et al., 2003; Meredith et al.,
2005), they also suggest that insecure attachment is
more generally related to the tendency to respond neg-
atively to pain (e.g., catastrophizing in response to
pain or appraising pain as a threat). The relationships
between these negative responses to pain and attach-
ment variables found in clinical samples could be
due to a third variable related to the experience of
chronic pain (e.g., a high level of disability leading
to both more negative response to pain and increased
attachment insecurity). The present ndings do not
exclude this possibility, but they do demonstrate that
relationships between adult attachment and negative
responses to pain exist prior to development of chron-
ic pain. Given this situation, longitudinal research
regarding the causal role of attachment in the devel-
opment of chronic pain is warranted.
The present study utilized a measure of romantic
attachment; however, the hypotheses were intended
to apply to attachment in general rather than the
more specic domain of romantic attachment. Attach-
ment has been conceptualized and assessed in many
dierent ways. In general, research (see Bartholomew
and Shaver, 1998) has indicated that these methods
assess a core set of relational tendencies and that
attachment measures share more variance with each
other when they assess the same domain of attach-
ment (e.g., peers, parents, romantic partners), are
based on similar underlying models (e.g., 3 category,
4 category, 1 global dimension, 2 dimensions), or uti-
lize a common assessment strategy (e.g., interviews,
self-report measures). Given such overlap, it is likely
that the ndings of the present study would have been
similar had another related measure of attachment
been used (e.g., a measure including models of self
and others related to peer relationships). Several
recent studies support this notion. For example, Watt
et al. (2005) investigated the relationships between
anxiety sensitivity and both romantic and close-rela-
tionship attachment dimensions and obtained similar
ndings across both types of attachment. More direct-
ly related to chronic pain, Meredith et al. (2005)
obtained ndings similar to those of the present study
when utilizing a measure of adult attachment that did
not refer to a specic type of close relationship (i.e.,
the Attachment Style Questionnaire; Feeney et al.,
1994).
In response to the growing empirical support for
postulates of fear-avoidance models of chronic pain,
fear of pain has become the focus of specic treatment
strategies (see Asmundson et al., 2004b). In brief,
treatments aimed at reducing fear of pain have been
based on strategies originally designed for treating
specic phobias, such as in vivo exposure. Findings
regarding this type of treatment are encouraging
(e.g., Linton et al., 2002; Vlaeyen et al., 2002). The
current study has implications for expanding this
approach to treating pain-related fear. At the most
 L.A. McWilliams, G.J.G. Asmundson / Pain 127 (2007) 2734
basic level, the present ndings suggest that those with
a negative model of self are likely to have the greatest
need for such a treatment (i.e., they possess the high-
est levels of fear of pain). As well, fear of pain in
those with negative models of self may also be main-
tained by their tendency to interpret pain and related
limitations as increasing their unworthiness. Incorpo-
rating strategies to address such interpersonal con-
cerns may also increase the ecacy of treatments
targeting fear of pain.
Attachment theory was originally applied to chronic
pain (i.e., Mikail et al., 1994) because of its potential
to provide a framework for understanding who develops
chronic pain following an acute injury. However, no
studies have tested the ability of attachment variables
to prospectively predict the development of chronic
pain. Given that several studies using a variety of attach-
ment measures have found that insecure attachment
(particularly insecurity characterized by a negative mod-
el of self) is associated with measures of constructs
implicated in the development of chronic pain (i.e., fear
of pain, hypervigilance, and catastrophizing), such
studies are warranted.
Acknowledgements
During the completion of this research, Dr. McWil-
liams was supported by a doctoral fellowship awarded
by the Social Sciences and Humanities Research Council
of Canada. Dr. Asmundson is supported by a Canadian
Institutes of Health Research Investigator Award.
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