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From the Department of Neuroscience, University of Rome, Rome, Italy.
Address correspondence and reprint requests to Alfonso Troisi, MD, Department of Neuroscience, University of Rome Tor Vergata, via Guattani 14, 00161 Rome, Italy. E-mail: alfonso.troisi{at}uniroma2.it
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ABSTRACT |
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Methods: Body dissatisfaction was measured using the Body Shape Questionnaire (BSQ), early separation anxiety was measured using the Separation Anxiety Symptom Inventory (SASI), and adult attachment style was measured using the Attachment Style Questionnaire (ASQ).
Results: In both anorectic and bulimic women, BSQ scores were strongly correlated with SASI and ASQ scores. In a hierarchical regression model controlling for the confounding effects of body mass index and depressive symptoms, early separation anxiety and preoccupied attachment emerged as significant predictors of high levels of body dissatisfaction.
Conclusions: Based on the cross-sectional findings of this study, insecure attachment appears to be a consistent correlate of negative body image evaluations in women with either anorexia nervosa or bulimia nervosa. If future prospective studies will confirm that an insecure style of attachment plays a role in promoting the development of body dissatisfaction, prevention and treatment of disordered eating pathology might be enhanced by focusing greater attention on attachment relationships.
Key Words: body dissatisfaction • separation anxiety • insecure attachment • anorexia nervosa • bulimia nervosa
Abbreviations: AN = anorexia nervosa; ASQ = Attachment Style Questionnaire; BDI = Beck Depression Inventory; BN = bulimia nervosa; BMI = body mass index; BSQ = Body Shape Questionnaire; SASI = Separation Anxiety Symptom Inventory.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONRESULTSDISCUSSIONNOTESREFERENCES |
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The origins of body dissatisfaction are likely to be multifactorial, with biological, family, and sociocultural features predominating (7,8). It has been suggested that an insecure style of attachment may be one of the factors implicated in the etiology of body dissatisfaction (2).
Attachment theory is one of the most influential models proposed to explain the relationship between early experience and adult personality. According to attachment theory, infants develop expectations about their caregivers’ availability and responsiveness based on the quality of parental care they receive. These expectations then serve as the basis for the development of mental representations of the self and of the other ("internal working models" in the terminology of attachment theory) that influence later psychosocial functioning (9). Infants with emotionally available caregivers develop a model of the self as loved and valued and a model of the other as loving. When infants instead have experiences that lead them to expect caregivers to be rejecting or undependable, they develop a model of the self as unworthy of love and a model of the other as unloving or rejecting. As adults, these persons do not expect that significant others will be available when needed, and they develop insecure strategies for coping with their distress (e.g., trying to "forget the whole thing" or wishing they felt differently and criticizing themselves) (Fig. 1).
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In insecurely attached individuals, the development of body dissatisfaction would be related to their decreased sense of self-worth and heightened expectation of rejection by others. These cognitions would make such individuals reliant on the gaining of acceptance from others and sensitive to society’s appearance-related messages (2,10). High levels of early separation anxiety and an insecure style of adult attachment are common psychological traits among women with anorexia nervosa or bulimia nervosa (11–14). Taken together, these findings suggest that body dissatisfaction and insecure attachment should be closely related in women with eating disorders.
Despite the heuristic value of such a hypothesis, the evidence linking insecure attachment with body dissatisfaction is limited to a single study showing that, in a sample of 305 preadolescent and adolescent girls, the insecurely attached subjects reported significantly greater weight concerns than did securely attached subjects and exhibited lower levels of self-esteem (10). To our knowledge, no study has analyzed the relationship between insecure attachment and body dissatisfaction in a clinical sample. In the present study, we analyzed the relationship among early separation anxiety, insecure attachment, and body dissatisfaction in adult women with eating disorders. We hypothesized that anorectic and bulimic women who reported higher levels of body dissatisfaction had a higher frequency of separation anxiety symptoms in childhood and higher scores on measures of insecure adult attachment.
Participants
The participants were 31 women with anorexia nervosa (AN; 26 with restricting type and five with binge-eating/purging type) and 65 women with bulimia nervosa (BN; 48 with purging type and 17 with nonpurging type) consecutively referred from January to October 2003 as outpatients to the Center for Eating Disorders of the University of Rome Tor Vergata. The University Intramural Ethical Committee approved all procedures and protocols, and, before clinical assessment, all participants were given a complete description of the study and granted written informed consent. The Structured Clinical Interview for DSM-IV Axis I Disorders, Clinical Version (SCID-CV) was used to confirm diagnosis (15). Height and weight were measured at the initial assessment to calculate the body mass index of each subject (BMI, weight in kilograms divided by height in meters squared).
Psychometric Assessment
To assess body dissatisfaction, we used the Body Shape Questionnaire (BSQ) (16). The BSQ is a 34-item, self-report inventory that measures general concerns about body shape, focusing in particular on the subjective experience of "feeling fat." Subjects responded to items according to how they have felt about their body shape over the past 4 weeks. Items are scored on a six-point Likert-type scale (1 = never to 6 = always) with a possible total score range from 34 to 204. Average scores of 71.9 (standard deviation [SD] = 23.6) for nonclinical college females and 136.9 (SD = 22.5) for individual diagnosed with BN have been reported by Cooper et al. (16). The BSQ has demonstrated high concurrent and discriminant validity and differentiates individuals with eating disorders from healthy control subjects.
To measure separation anxiety and attachment style, we used the Italian versions (17) of the Separation Anxiety Symptom Inventory (SASI) (18) and the Attachment Style Questionnaire (ASQ) (19). The SASI evaluates retrospective memories of separation anxiety symptoms and their frequency in childhood. It is a 15-item self-report questionnaire with individual items being scored according to a frequency rating (0–3). Individual items are summed to derive a total score. The SASI has been shown to have a coherent factor structure, high internal consistency, and sound test–retest reliability. Serial SASI scores have been shown to be independent of changes in respondents’ levels of anxiety and depression over time, suggesting that scoring remains stable despite shifts in the emotional status of the respondent (18). Indirect validity estimates have included concordance of SASI scores with retrospective diagnoses of juvenile separation anxiety disorder made "blind" by clinically experienced interviewers and associations of SASI scores with histories of absenteeism from school and reports of school anxiety, respectively (20). In a further test of the SASI’s validity, each member of twin pairs was asked to complete a checklist of descriptors depicting early insecure behaviors observed in the other member of the pair. SASI scores corresponded with observer twins’ ratings on the proband, thus providing a crude index of the SASI’s concurrent validity (18).
The ASQ is a 40-item self-report questionnaire with individual items being scored on a six-point scale from 1 (totally disagree) to 6 (totally agree). The ASQ includes five scales derived from principal-components analysis: confidence (in self and others), discomfort with closeness, need for approval, preoccupation with relationships, and relationships as secondary (to achievement). Confidence is a factor representing secure attachment, whereas each of the other four scales represents a particular aspect of insecure attachment (19). The need for approval scale and the preoccupation with relationships scale assess the anxiety (about abandonment) dimension of the attachment style, whereas the discomfort with closeness scale and the relationships as secondary scale pertain primarily to the avoidance (of intimacy) dimension of the attachment style. The scales have high levels of internal consistency and acceptable levels of test–retest reliability. The validity of the ASQ is indicated by a number of findings: the pattern of associations with previous measures of attachment style, the predictable patterns of correlations with measures of family functioning and personality, and the lack of correlation with Lie scores of the Eysenck Personality Questionnaire (19).
The Beck Depression Inventory (BDI) (21) was used to measure the presence and severity of depressive symptoms. We included the BDI among the psychometric measures to control for the confounding effect of depression on self-assessment of body image, retrospective memories of separation anxiety symptoms, and attachment style. Subjects were asked to place a mark next to the statement best describing how they felt over the past week for each of 21 items. Four possible choices, ranging in severity from a score of "0" indicating little distress to a score of "3" indicating much distress, were offered for each item. Scores were summed across all items with a higher overall score signifying higher levels of depression. Normative data have shown that clinically depressed individuals typically score between 10 and 30, ranging from mild to severe depression.
Statistical Analysis
Comparisons between the two groups were performed using t test. Coefficients of correlation were used to calculate bivariate correlations between variables. Hierarchical regression analysis was used to identify the significant predictors of the BSQ score in the entire sample. Collinearity diagnostics based on eigenvalues of the scaled and uncentered crossproducts matrix, variation inflation factors (VIF), and tolerances for individual variables were used to exclude multicollinearity among the independent variables. Analysis was performed on a personal computer using SPSS for Windows, version 10.0.5 (SPSS, Inc., Chicago, IL).
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RESULTS |
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TOPABSTRACTINTRODUCTIONRESULTSDISCUSSIONNOTESREFERENCES |
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In the entire sample, the BSQ score was positively correlated with the BMI (r = 0.29, p = .005) and the BDI score (r = 0.48, p = .0001) but not with age (r = –0.02, p = .86), education (r = –0.03, p = .79), age at onset (r = –0.09, p = .37), or illness duration (r = 0.07, p = .51). To analyze the relationship among body dissatisfaction, early separation anxiety, and adult attachment style, we first calculated bivariate correlations among the BSQ score, the SASI, and the five ASQ scales. In both the anorectic and bulimic women, the BSQ score was strongly correlated with the SASI and each of the five scales of the ASQ (Table 2). Then, we conducted a hierarchical regression analysis to ascertain which were the best predictors of body dissatisfaction in the entire sample. The independent variables entered into the first block were the diagnostic group (coded as 1 = AN, 2 = BN), the BMI, and the BDI. The independent variables entered into the second block were the SASI and the five ASQ scales. The dependent variable was the BSQ score. The model was highly significant (F [5, 95] = 16.19, p < .0001), explaining 44% (adjusted R2) of the variance in the BSQ score. After controlling for the effects of the BMI and depression, the SASI and the ASQ need for approval scale emerged as significant predictors of the BSQ score (Table 3).
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DISCUSSION |
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Because of the cross-sectional design of this study, the causal relationship between insecure attachment and body dissatisfaction cannot be determined. However, two considerations make it unlikely the hypothesis that insecure attachment is a consequence of body dissatisfaction. First, attachment style is a personality factor that develops early in life and remains relatively stable across the lifespan (22,23). Second, among the women of this study, higher levels of body dissatisfaction were associated not only with an insecure style of adult attachment, but also with a higher frequency of separation anxiety symptoms in childhood. Thus, it is reasonable to assume that, in the developmental pathway leading to body dissatisfaction, attachment-related childhood experiences influence subjective evaluations of one’s physical appearance and that the development of an insecure style of attachment becomes a risk factor for the successive emergence of negative body image evaluations. An alternative hypothesis is that the associations among early separation anxiety, insecure attachment, and body dissatisfaction are attributable to the presence of an underlying variable (e.g., anxiety proneness) routed in temperament. The data collected in the present study are not useful for testing the validity of these two alternative hypotheses. However, it is worth noting that previous studies have shown that attachment security is only modestly related to temperament traits (24,25).
It has been hypothesized that, in insecurely attached individuals, the development of body dissatisfaction is related to their decreased sense of self-worth and heightened sensitivity to society’s appearance-related messages (2,10). In line with such a hypothesis, we found that, among the five scales of the ASQ, the best predictor of body dissatisfaction was the need for approval scale. People with a high score on this scale have a preoccupied attachment style and their self-esteem tends to fluctuate dramatically in response to perceived approval or rejection from others (26). Because of their heightened concerns over acceptance and rejection, people with a preoccupied attachment style base their self-esteem on sources that depend on others’ reactions and are conditional in nature such as physical attractiveness (27). Not surprisingly, body dissatisfaction may easily develop in individuals with a preoccupied attachment style who combine concerns over physical attractiveness with an internalized negative model of the self.
This study has important limitations that must be considered in interpreting the results. First, this study used a clinical sample of women with eating disorders with no other comparison groups. Thus, it is not known whether the relationship among body dissatisfaction, early separation anxiety, and insecure attachment would also apply to other psychiatric or nonpsychiatric samples of adult women or whether it is specific to AN and BN. Second, we used a retrospective measure to assess the frequency of symptoms of separation anxiety during childhood. Retrospective data may be subject to faulty recall or systematic distortions. Although prospective studies are clearly desirable in delineating the role of separation anxiety as an early risk factor to body dissatisfaction, such investigations face daunting methodological difficulties. Until such methodological problems can be overcome, reliance will have to be placed on a variety of sources of information, including retrospective data, to study the pathogenic role of early separation anxiety. Third, we did not collect data about traumatic experiences. A growing body of literature suggests that a trauma history can influence an individual’s vulnerability to eating pathology and that posttraumatic stress disorder (PTSD) commonly co-occurs with anorexia or bulimia (28). Although none of the women of this study fulfilled the DSM-IV criteria for a diagnosis of PTSD, we cannot exclude that, in a subset of patients with eating disorders, the co-occurrence of insecure attachment and negative body image evaluations is the result of traumatic experiences.
There is mounting evidence that elevated body dissatisfaction is a risk factor for eating disorders (1–3) and that this relation is mediated by increases in dieting and negative affect (29). If future prospective studies will confirm that an insecure style of attachment plays a role in promoting the development of body dissatisfaction, prevention and treatment of eating pathology might be enhanced by focusing greater attention on attachment relationships. In the area of eating disorders, selected prevention interventions focusing on one risk factor seem to be more effective than universal programs focusing on a plethora of putative risk factors (30,31). Studies of clinical and nonclinical populations have repeatedly shown that persons with eating disorders have a high prevalence of insecure attachment and a high frequency of adverse early experiences with their attachment figures (11–14). Based on these findings, prevention programs might be strengthened by the inclusion of a module for the assessment of attachment and, in high-risk populations, selected prevention interventions could primarily target individuals with insecure attachment. Interventions that target dysfunctional attachment styles and aim at rendering insecure individuals more resilient to sociocultural pressure to be thin may prove useful in interrupting the developmental pathway from insecure attachment through body dissatisfaction to eating pathology.
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NOTES |
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Received for publication August 16, 2005; revision received November 22, 2005.
DOI:10.1097/01.psy.0000204923.09390.5b
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This article has been cited by other articles:
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  R. O'Shaughnessy and R. Dallos Attachment Research and Eating Disorders: A Review of the Literature Clinical Child Psychology and Psychiatry, October 1, 2009; 14(4): 559 - 574. [Abstract] [PDF]
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