Recently, Nielsen et al. (2017) investigated the relationship between adult attachment style and anxiety disorders and the mediating role of emotion regulation in a sample of 147 participants with 90 participants diagnosed with anxiety disorders. Results of this study revealed an association between anxiety and attachment anxiety (b=4.60, p < .0001). Also, emotion dysregulation was significantly related to attachment anxiety (b=10.30, p < .0001) and anxiety symptoms (b= 1.06, p < .0001).
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However, when using attachment anxiety in the mediation model, avoidant attachment was not correlated with anxiety or emotion regulation.
In a study of 18-48 years old adults, Marganska et al. (2013) reported a vice versa correlation between secure attachment, emotion dysregulation and symptoms of generalized anxiety disorder and depression. Preoccupied and fearful avoidant attachment presented a significant association with depression (b =.31, and .25, respectively, p < .01) and generalized anxiety disorder (b= .25, and .18, respectively, p < .01). This study indicated that emotion dysregulation was positively related to insecure attachment and also mediated the relation between attachment style and depression and anxiety disorder.
Garrison et al. (2012) investigated adult attachment and depression symptoms as a predictor of individual‘s emotional disclosure in a community sample of 121 college students. Emotional disclosure as a means of emotion regulation in this paper is defined as sharing information about one‘s emotional experiences. Individuals with higher level of depression symptoms reported weaker emotional disclosure during their engagement in emotional events. This finding shows that depression symptoms are relevant to emotional disclosure. They also found a negative association between attachment avoidance and both generalized disclosure tendencies and daily emotional disclosure (b= −.14 and −.04, p < .05). Attachment anxiety, on the other hand, indicated a moderation role between daily event intensity and disclosure relation (b= .12, p < .05).
In another study concerning emotional disclosure and mental disease, Zech et al. (2006) investigated depressive affect in 198 patients visiting a general practitioner (GP) to find whether it is related to attachment, emotional disclosure and health complaints. Individuals with anxious attachment showed more depressive affect (b= .30, p < .001) and they disclose their emotion (r= .31). In contrast, avoidant attachment was negatively related to depressive affect (b=0.35, p < .001) and the patients also displayed less emotional disclosure (r= –.22). Nonetheless they had greater physical problems.
3.2. Distress and adult psychopathology
McDonald et al. (2016) examined the relation between psychological disorder and mindfulness taking into account the role of attachment and emotion regulation in a community sample of 17-24 year-old adults. In this study, psychological distress had a positive correlation with emotion regulation and attachment anxiety. A bootstrap confidence interval (BCI) revealed that emotion dysregulation and attachment anxiety were significant mediators of the relationship between mindfulness and stress (95% BCI −1.70 to −0.99; 95% BCI −0.51 to −0.12). However, attachment avoidance did not show a significant relation to psychological distress and mindfulness, but was correlated with dysfunctional emotion regulation. Also, they found a strong indirect effect of dysfunctional emotion regulation in comparison with attachment anxiety when they measured distress.
In addition, more recently, Van der Meer et al. (2015) investigated a community sample of 98 adults with 50% risk in neurogenic disorder such as Huntington‘s disease, to detect whether an insecure attachment style and emotion regulation is associated with distress before and after predictive testing. They found that attachment anxiety and level of distress were associated before the test (b=0.239, p=0.03). Also, research has shown that attachment anxiety displayed distress up to 2 months after testing. In contrast, attachment avoidance was not
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associated before and after test. Besides this, the results reported that maladaptive emotion regulation did not have an effect after predictive testing.
Similarly, McCarthy et al. (2006) found support for the mediating role of emotion regulation expectancies and preventive coping recourse between attachment and stress outcomes (stress symptoms and stress produced emotion). Also, parental attachment was associated with stress symptoms and stress-produced emotions (r= −.45 and −.56). The authors suggested that mood-regulation expectancies in stressful situations need both sufficient preventive coping resources and an attachment background.
Jones et al. (2014) conducted a longitudinal study in a sample of 227 adolescents and their parents. They examined the relation between mother‘s attachment and their response to their adolescent‘s negative emotions and also whether emotion regulation could mediate this relation. Negative emotions included: distress responses (e.g., becoming anxious), harsh responses (e.g., invalidating emotion) and supportive responses (e.g., helping to solve the problem). Mothers with avoidance attachment (b = .20, p < .05) or anxiety attachment (b = .47, SE = .14, p < .01) exhibited more difficulty with emotion regulation. Also, emotion dysregulation was positively correlated to mothers‘ distress responses to their adolescents‘ negative emotions (b = .53, p < .01). Mothers were more likely to endorse distress and harsh responses, and they displayed greater difficulties with emotion regulation. The authors suggested that difficulties with emotion regulation mediated the relation between maternal attachment style and response to adolescents‘ negative emotions.
In another longitudinal study, Pascuzzo et al. (2015) investigated the role of attachment and emotion regulation strategies in a 10-year longitudinal design on adult symptoms of psychopathology which included 33 young women and 17 young men. In this study, participants filled in various questionnaires, such as attachment security to peers and parents, emotion regulation and self-reported symptoms of psychopathology in different ages. Adolescents who reported higher attachment insecurity to their parents showed greater symptoms of psychopathology in their adulthood (b=.64, p < .01) and this relationship was partially mediated by emotion-focused strategies. Moreover, the association between anxious romantic attachment in young adulthood and adult psychopathology was fully mediated by emotion-focused strategies.
3.3. Well-being
Karreman and Vingerhoets (2012) also investigated the association between attachment and well-being by considering the role of emotion regulation and resilience as mediators amongst 632 individuals 16-67 years old. While secure and dismissing attachment was associated with high well-being (b = 8.57, p < .001 and b = 3.77, p < .01), preoccupied attachment negatively predicted well-being (b = −4.75, p < .001). However, fearful attachment was not associated with well-being and suppression could not mediate the relation between attachment and well-being. The results showed that all types of attachment styles affected well-being through the reappraisal dimension of emotion regulation and resilience.
3.4. Borderline and somatoform disorder
Van Dijke and Ford (2015) examined attachment and emotion dysregulation in a community sample of 472 patients with borderline personality disorder (BPD), somatoform disorder (SoD) or another psychiatric disorder. Results showed that
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under-regulation was associated to attachment anxiety, namely fear of abandonment (r = 0.30, p < 0.001). However, over-regulation correlated with attachment avoidance, namely fear of closeness (r = 0.44, p < 0.001). Furthermore, BPD was associated with under-regulation of affect and fear of abandonment. The SoD group tended to over-regulate and was associated with fears of abandonment or closeness. Also, Fossati et al. (2016) recently provided an investigation among 354 non-clinical adults and evaluated the mediation role of emotion regulation in the relationship between child trauma history, adult attachment and BPD. Results showed that childhood (emotional) abuse and adult attachment were positively associated with emotion dysregulation and BPD features (r = .41, p < .001). BPD features were associated with both preoccupied/fearful and anxious/ambivalent insecure attachment. However, only preoccupied/fearful attachment was associated with both emotion dysregulation and BPD features. Furthermore, emotion dysregulation significantly moderated the relationship between both emotional abuse and fearful/preoccupied attachment and BPD features.
3.5. Eating disorder
Han and Pistole (2014) investigated emotion regulation as a mediator of attachment insecurity and binge eating in a sample of 381 students who were recruited in an online survey. Insecure attachment and binge eating were positively correlated (b = .37, p < .001). The results also provide evidence for a full mediating role of emotion regulation for the insecure attachment and binge eating association. Additionally, in other research regarding binge eating, Shakory et al., (2015) examined binge eating and the role of insecure attachment and emotion regulation among 1388 morbidly obese patients with binge eating who are bariatric surgery candidates. Results revealed a positive correlation between anxiety attachment and binge eating (b = 0.02, t=6.36, p = .001). However, avoidance attachment was not associated with binge eating unless difficulties with emotion regulation controlled as a mediator, in which case a significant association appeared (b = −0.10, p = .006). Moreover, difficulty of emotion regulation mediated the relationship between attachment avoidance/anxious and binge eating.
In a further study, Ty and Francis. (2013) also examined disordered eating and insecure attachment in women by considering the mediation role of emotion regulation and social comparison. This research identified a positive and significant association between anxious and avoidant attachment and eating disorder symptoms and also with emotion dysregulation. However, attachment anxiety towards partner showed the strongest correlation with eating disorder (r = .34, p < .001).
3.6. Child abuse
In a clinical sample of 109 women with childhood abuse histories, Cloitre et al. (2008) identified a correlation between insecure attachment and psychiatric outcomes, and insecure participants showed more problematic functions compared to secure participants (b=.25, p <.05), with emotion regulation playing a role in this relationship (b=.09, p <.05). Nonetheless, the author could not detect results for the dismissing group due to the small number of participants in this category.
One study, which included 361 undergraduate students, investigated attachment style and emotion regulation in relation to child maltreatment and types of risk behaviors (Oshri et al., 2015). The authors found that variables such as
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emotional abuse were associated with anxious (b = .30, p = .001) and avoidant (b = .15, p = .010) attachment. Also sexual abuse alternatively was related to anxious (b = .11, p = .013) and avoidant attachment (b = .19, p = .001). They were also related to abundant risk behaviors and emotion dysregulation. This study demonstrated a different association in various types of abuse. Verbal abuse, for instance, was not related to any dimension of emotion regulation or attachment styles (Oshri et al., 2015).
3.7. Dementia disorder
Magai and Cohen (1998) conducted a study measuring attachment and emotion regulation in elderly dementia patients and their relation to caregiver burden. Results showed that the burden for caregivers who care for an individual with avoidant and ambivalent premorbid attachment was higher than those with secure premorbid attachment (t = –3.54, p < .02, t = 3.51, p < .001). This study showed that avoidant premorbid attachment style was also associated with premorbid emotions of anger, contempt and reserve and in contrast with secure individuals; they had greater levels of disturbance and paranoid delusions. Ambivalent premorbid attachment, on the other hand, was associated with premorbid emotions of sadness and was related to higher levels of anxiety and depression.
3.8. Posttraumatic stress disorder
Benoit et al. (2010) investigated emotion regulation as a mediator between attachment and Posttraumatic stress disorder (PTSD) symptoms in a sample of 33 adults. The finding showed that attachment security was negatively associated with all dimensions of PTSD symptoms at 12 weeks post trauma. Also, individuals with secure attachment tended less to utilize emotion-focused strategies to cope with traumatic experiences (r= –.47, p= .004). Moreover, emotion-focused strategies and substance use – two dimensions of emotion regulation examined in the study – mediated the association between attachment and PTSD symptoms.
- Discussion
4.1. Attachment, Emotion regulation and mental disorders
In this literature review, a moderate association between attachment style and mental disorders emerged. Additionally, regarding the potential role of emotion regulation, individuals with insecure attachment had more difficulties in emotion regulation; therefore, the group with insecure attachment and emotion dysregulation showed an increased risk for mental disorders.
In spite of the results demonstrating the relation between insecure attachment and mental illness, some insight into avoidant attachment examined in several studies provided different results that need to be discussed. Although most studies reviewed in this paper showed an association between emotion regulation, attachment and mental health, in some studies emotion regulation failed to be a mediator of this relationship. For example, Shakory et al. (2015) found no positive association between avoidant attachment and binge eating. It should be noted, however, that individuals with avoidant attachment downregulate their emotions with suppression and denial of negative emotions (Tasca & Balfour, 2014; Shaver et al., 2008). In addition, in a more recent study, Nielsen et al. (2017) found no relation between avoidant attachment and both anxiety disorder and emotion regulation, while it was covariant with attachment anxiety. Also, Van der Meer et al. (2015) and McDonald et al. (2016)
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found that there was no correlation between avoidant attachment and psychological distress. Similarly, Karreman and Vingerhoets (2012) found no direct correlation between fearful attachment and well-being when controlling for other attachment styles scores. Moreover, although in this study suppression of emotion expression was associated with attachment and well-being, it failed to mediate this link.
Mikulincer and Shaver (2007) suggested that individuals with relatively high levels of avoidant attachment may find it difficult to express their thoughts and emotions, or may not be aware of having problems, and are known to under-report symptoms of distress. Also, these authors believe that the level of stress experienced by a non-clinical sample might not be enough to activate the typical pattern of responses associated with avoidant attachment. Moreover, individuals with an avoidant attachment pattern tend to dismiss or downregulate distressing emotions through emotional suppression or dissociation, and are less inclined to report distress.
With regard to gender aspects, the study of McDonald et al. (2016) is noteworthy since it includes mainly women. For instance, it is possible that women are more inclined to report anxious, as opposed to avoidant attachment (Ainsworth et al. 1978).
Furthermore, Garrison et al. (2011) claimed that avoidant attachment is negatively related to generalized disclosure tendencies and daily emotional disclosure. To explain this, they assume individuals who are high in avoidant attachment tend to suppress their emotions and do not seek social support when they are distressed (Mikulincer et al., 2003). Also, the findings of Zech et al. (2006) showed that avoidant attachment was not associated with emotion disclosure and depressive affect. However, the authors explained that while there is a growing independency in avoidant individuals, they would not accept negative feelings. Moreover, to suppress affective reactions, individuals with avoidant attachment utilize defensive strategies (Mikulincer & Orbach, 1995).
In another study examining attachment style with anxiety and depression disorders, avoidant (dismissive) attachment was associated only with depression whereas fearful avoidant and preoccupied attachment predicted both depression and anxiety disorders (Marganska et al., 2013). To interpret this finding, both styles (fearful avoidant and preoccupied) might be characterized by hyper-activating emotion regulation strategies that involve increased monitoring of threats to the self, especially social threats such as abandonment. In addition, the hyper-activating strategies used by preoccupied and fearful individuals frequently involve attempts to elicit care and attention from others, often through clinging behaviors (Mikulincer et al., 2003). Meanwhile, Roberts et al. (1996) found that individuals with higher level of avoidant attachment reported more depressive symptoms that are associated with their negative models of the self. Moreover, Magi and Cohen (1998) found that those dementia patients who possess avoidant attachment had fewer depression and anxiety disorders than individuals with secure and anxious attachment.
However, it should be noted that individuals with avoidant attachment are believed to under-report their depressive symptoms (Dozier & Kobak, 1992). Furthermore, Pascuzzo et al. (2015) also indicated no relation between avoidant romantic attachment orientation and the global index of psychopathology, and emotion regulation (namely, emotion-focused strategy) partially mediated the association between insecure parent-adolescent attachment and adult symptoms
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of psychopathology. Nevertheless, some studies showed that under stress conditions avoidance might be related to the development of symptoms of psychopathology (Simpson & Rholes, 2004; Berant et al. 2001; Ein-Dor et al. 2010). However, the low-risk sample in this research, as the author found, might be a reason to restrict the high-level stress by participants. Also, according to minimization of distress signal strategy in individuals with avoidant attachment, under-reporting of symptom of psychopathology might be feasible (Mikulincer & Shaver, 2007, 2008).
4.2. Conclusions and Future Directions
This review of existing papers on the association of attachment and mental health with emotion regulation as a mediating variable reveals some limitations that need to be addressed by future investigations. In most papers in this review, a cross-sectional design was used, which presents a restriction with regard to the interpretation of the study results. A cross-sectional design may be prone to non-response bias if participants who consent to take part in the study differ from those who do not participate, resulting in a sample that is not representative of the population. However, it is possible to record exposure to many risk factors and to assess more than one outcome in a cross-sectional study (Philip Sedgwick, 2014). Therefore, further research is recommended using longitudinal and experimental designs to uncover causal links in the relationship between adult attachment, mental disorder and emotion regulation with more detailed information.
The samples included non-clinical participants in most studies, which could affect results; furthermore, generalizing the results with non-clinical samples to clinical samples is not feasible. To clarify this, investigating clinical populations could be an essential issue to provide variety of knowledge in respect of the relationships between the variables and ultimately to come up with more accurate conclusions. Thus, additional studies are needed to examine clinical samples regarding the attachment in adulthood and mental health and the role of emotion regulation in the future.
Additionally, sample size in some studies was not sufficient enough to be adequately powered. This is another reason why generalizing the results is problematic. It would be an advantage for future investigations to provide an equal sample with both men and women and endeavor to encompass a large community sample as well.
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