Attachment theory: a model for health care utilization and somatization
Ciechanowski PS, Walker EA, Katon WJ, Russo JE;
Commented by , 19 Aug 2002
Background
Bowlby conceptualized attachment behavior as a mammalian trait designed to maximize survival in infants (1). Early attachment patterns cluster in recognized patterns and are maintained over a lifetime via internal working models, whereby models of self and other vary from positive expectations (resiliency of self, responsiveness of others) to negative expectations (fragile self, unavailable other).
Predominant attachment styles reflect an individual’s position on these two dimensions, leading to a four-category model: secure and three insecure attachment styles – dismissing, preoccupied and fearful.
Purpose
The authors empirically evaluate attachment behavior as a useful model for understanding symptom perception and health care utilization.
They hypothesize individuals with a negative other model (dismissing, fearful) will have lower health care utilization than those with a positive other model (secure, preoccupied), based on prior learning that others are likely to reject their attempts to obtain support.
Additionally, individuals with a negative self model (preoccupied, fearful) will be more likely to report somatic symptoms due to their tendency to focus on negative affect.
Methods
The 30-item RSQ and 4-item RQ, valid and reliable instruments determining adult attachment style, were sent to 1119 adult female primary care health maintenance organization (HMO) patients previously enrolled in a large NIMH study exploring health care utilization and perceived health status.
In the primary study, physical complaints were evaluated using the somatization section of the Diagnostic Interview Schedule, corresponding primary care costs and utilization were obtained from HMO data.
Ratings of chronic medical comorbidity were obtained from the CDS, an index derived from pharmacy data. Depression was screened for using the MHI-5 of the SF-36. Demographic data was also obtained.
Analysis of covariance (ANCOVA) and Poisson regressions were used to determine whether number of somatic symptoms and primary care utilization and costs varied as a function of attachment style.
Any demographic or clinical characteristics significantly different between attachment groups in bivariate analyses were included as covariates.
Results
701 questionnaires were returned, yielding a response rate of 63%. A secure attachment was found in 34% of respondents, whereas 21%, 22% and 23% had fearful, preoccupied and dismissing attachments, respectively.
Attachment style was significantly associated with somatic symptom reporting, with preoccupied and fearful patients having a greater number of physical symptoms compared to dismissing and secure patients.
Attachment was also associated with primary care utilization and costs. Preoccupied patients had the highest utilization and costs, while fearful patients had the lowest.
Discussion
These findings yield empiric support for adult attachment styles as useful parameters towards understanding symptom perception and health care utilization. An advantage of the attachment model is its broad application to all patients, not simply patients with Axis I or II pathology.
Moreover, the attachment understanding of a patient can be easily communicated to staff (medical or nonmedical) and to patients. This understanding can guide clinical interventions towards the improvement of health care provision (2).
For example, the recent finding of poor glycemic control in diabetics with avoidant attachment styles (3) can be targeted by a respect for such patients “compulsive self-reliance” and a focus on empowerment as opposed to scheduling multiple visits.
On the other hand high utilizers, reflecting a preoccupied attachment, would benefit from regularly scheduled brief frequent visits. The most significant study limitation is it being limited to female patients, thus the data may not be generalizable to male populations.