Document Type : Original Article

Authors

1 Department of Clinical Psychology, Substance Abuse and Dependence Research Center, University of Social Welfare and Rehabilitation Sciences

2 Department of Clinical Psychology, Iran University of Medical Sciences, Tehran, Iran

Abstract

INTRODUCTION: In spite of our general knowledge about psychological roots and defects of
developmental processes in the formation of somatic symptoms, the effect of the interaction of
developmental components with cognitive‑emotional variables is unclear. Previous researches
suggest that individuals with insecure attachment may have a higher risk to experience of somatic
symptoms. The main aim of this study is “Modeling the Relationship between Attachment Styles and
Somatic Symptoms with the Mediating Role of Emotional Processing.”
MATERIALS AND METHODS: This study was a descriptive‑correlational study. Two hundred and
twenty individuals aged 18–59 years living in Tehran were selected by available sampling from
the general population. Collins and Reed’s Adult Attachment Scale, Baker’s Emotional Processing
Scale, and Patient Health Questionnaire were used to collecting data. Data analysis was performed
by Pearson correlation and independent t‑test. The conceptual model presented in this study was
tested with a path analysis approach.
RESULTS: Given the Chi‑squared size (² = 1.214; P > 0.05), it can be said that the proposed
conceptual model fits well with the observed model. Besides, checking the other absolute and relative
indices also shows a very good fit of the model.
CONCLUSION: Our results showed that when the reciprocal effects of attachment styles were
controlled, secure attachment could be considered as a protective factor against deficits in emotional
processing and somatization of negative emotions. On the other hand, we found that when the
dominant attachment style in individuals was anxiety based, it could be possible that they experience
deficiency in the processing of emotion and more severe somatic symptoms.


Keywords

1. Association AP. Diagnostic and Statistical Manual of Mental
Disorders (DSM‑5®). Arlington, VA: American Psychiatric
Publishing; 2013.
2. Sattel H, Lahmann C, Gündel H, Guthrie E, Kruse J,
Noll‑Hussong M, et al. Brief psychodynamic interpersonal
psychotherapy for patients with multisomatoform disorder:
Randomised controlled trial. Br J Psychiatry 2012;200:60‑7.
3. Subic‑Wrana C, Beutel ME, Knebel A, Lane RD. Theory of mind
and emotional awareness deficits in patients with somatoform
disorders. Psychosom Med 2010;72:404‑11.
4. Beck T, Breuss M, Kumnig M, Schüßler G. The first step is the
hardest ‑ emotion recognition in patients with somatoform
disorders. Z Psychosom Med Psychother 2013;59:385‑90.
5. Castelli L, De Santis F, De Giorgi I, Deregibus A, Tesio V,
Leombruni P, et al. Alexithymia, anger and psychological distress in patients with myofascial pain: A case‑control study. Front
Psychol 2013;4:490.
6. De GuchtV, HeiserW. Alexithymia and somatisation: Quantitative
review of the literature. J Psychosom Res 2003;54:425‑34.
7. Mills A. Somatic Symptom and Related Disorders. Encyclopedia
of Clinical Neuropsychology 2017; 1:1 Springer, New York, NY.
8. Phillips ML, Drevets WC, Rauch SL, Lane R. Neurobiology
of emotion perception I: The neural basis of normal emotion
perception. Biol Psychiatry 2003;54:504‑14.
9. Bowlby J. The making and breaking of affectional bonds. II. Some
principles of psychotherapy. The fiftieth Maudsley Lecture. Br J
Psychiatry 1977;130:421‑31.
10. Payne H, Brooks SD. Medically unexplained symptoms and
attachment theory: The BodyMind Approach®. Front Psychol
2019;10:1818.
11. Luyten P, Mayes L, Fonagy P, Van Houdenhove B. The
interpersonal regulation of stress: A developmental framework.
Manuscript Submitted for Publication; 2014.
12. Luyten P, Kempke S. Psychodynamic factors in functional somatic
symptomsand syndromes. In P. Luyten, J. Vandenberghe, &
B. Van Houdenhove (Eds.), Listening to the body: Beyond dualism
(pp. 59–73). Tielt: Lannoo. 2010.
13. Luyten P, van Houdenhove B, Egle U. The role of childhood
trauma in chronic pain and fatigue.Chapter: 2, Publisher:
Routledge; pp. 37‑64, 2008.
14. WestM, LivesleyWJ, Reiffer L, SheldonA. The place of attachment
in the life events model of stress and illness. Can J Psychiatry
1986;31:202‑7.
15. Lewczuk K, Kobylińska D, Marchlewska M, Krysztofiak M,
Glica A, Moiseeva V. Adult attachment and health symptoms: The
mediating role of emotion regulation difficulties. Curr Psychol
2018:1‑14.
16. Feeney JA. Implications of attachment style for patterns of health
and illness. Child Care Health Dev 2000;26:277‑88.
17. MaunderRG, HunterJJ. Attachment and psychosomatic medicine:
Developmental contributions to stress and disease. Psychosom
Med 2001;63:556‑67.
18. Pietromonaco PR, DeVito CC, Ge F, Lembke J. Health and
attachment processes. Attachment theory and research: New
directions and emerging themes. NY, 2015. p. 287‑318.
19. Mikulincer M, Shaver PR, Pereg D. Attachment theory and
affect regulation: The dynamics, development, and cognitive
consequences of attachment‑related strategies. Motiv Emot
2003;27:77‑102.
20. Waters SF, Virmani EA, Thompson RA, Meyer S, Raikes HA,
Jochem R. Emotion regulation and attachment: Unpacking two
constructs and their association. J Psychopathol Behav Assess
2010;32:37‑47.
21. Okur Güney ZE, Sattel H, Witthöft M, Henningsen P. Emotion
regulation in patients with somatic symptom and related
disorders: A systematic review. PLoS One 2019;14:e0217277.
22. Kotler T, Buzwell S, Romeo Y, Bowland J. Avoidant
attachment as a risk factor for health. Br J Med Psychol 1994;67
(Pt 3):237‑45.
23. MarganskaA, GallagherM, MirandaR. Adult attachment, emotion
dysregulation, and symptoms of depression and generalized
anxiety disorder. Am J Orthopsychiatry 2013;83:131‑41.
24. Burton C, Weller D, Sharpe M. Functional somatic symptoms and
psychological states: An electronic diary study. Psychosom Med
2009;71:77‑83.
25. Taylor GJ. Recent developments in alexithymia theory and
research. Can J Psychiatry 2000;45:134‑42.
26. de Timary P, Roy E, Luminet O, Fillée C, Mikolajczak M.
Relationship between alexithymia, alexithymia factors and
salivary cortisol in men exposed to a social stress test.
Psychoneuroendocrinology 2008;33:1160‑4.
27. Uher T. Alexithymia and immune dysregulation: A critical review.
Act Nerv Super 2010;52:40‑4.
28. Hadjistavropoulos HD, Craig KD. Acute and chronic low back
pain: Cognitive, affective, and behavioral dimensions. J Consult
Clin Psychol 1994;62:341‑9.
29. Gul A, Ahmad H. Cognitive deficits and emotion regulation
strategies in patients with psychogenic nonepileptic seizures:
A task‑switching study. Epilepsy Behav 2014;32:108‑13.
30. Okur Güney Z, Sattel H, Cardone D, Merla A. Assessing embodied
interpersonal emotion regulation in somatic symptom disorders:
A case study. Front Psychol 2015;6:68.
31. Zautra AJ, Fasman R, Reich JW, Harakas P, Johnson LM,
Olmsted ME, et al. Fibromyalgia: Evidence for deficits in positive
affect regulation. Psychosom Med 2005;67:147‑55.
32. Pollatos O, Herbert BM, Wankner S, Dietel A, Wachsmuth C,
Henningsen P, et al. Autonomic imbalance is associated with
reduced facial recognition in somatoform disorders. J Psychosom
Res 2011;71:232‑9.
33. Waller E, Scheidt CE. Somatoform disorders as disorders of
affect regulation: A development perspective. Int Rev Psychiatry
2006;18:13‑24.
34. Nielsen SK, Lønfeldt N, Wolitzky‑Taylor KB, Hageman I,
Vangkilde S, Daniel SI. Adult attachment style and anxiety – The
mediating role of emotion regulation. J Affect Disord
2017;218:253‑9.
35. Stanton SC, Campbell L. Perceived social support moderates the
link between attachment anxiety and health outcomes. PLoS One
2014;9:e95358.
36. Baker R, Thomas S, Thomas PW, Gower P, Santonastaso M,
Whittlesea A. The Emotional Processing Scale: Scale
refinement and abridgement (EPS‑25). J Psychosom Res
2010;68:83‑8.
37. Collins NL, Read S. Revised adult attachment scale. Unpublished
instrument, scoring instructions and reliability information,
Department of Psychology, University of California, Santa
Barbara; 1996.
38. Kroenke K, Spitzer RL, Williams JB. The PHQ‑15: Validity of a
new measure for evaluating the severity of somatic symptoms.
Psychosom Med 2002;64:258‑66.
39. GierkB, KohlmannS, ToussaintA, WahlI, Brünahl CA, MurrayAM,
et al. Assessing somatic symptom burden: A psychometric
comparison of the Patient Health Questionnaire‑15 (PHQ‑15)
and the Somatic Symptom Scale‑8 (SSS‑8). J Psychosom Res
2015;78:352‑5.
40. Lee S, CreedFH, MaYL, Leung CM. Somatic symptom burden and
health anxiety in the population and their correlates. J Psychosom
Res 2015;78:71‑6.
41. Xiong N, Fritzsche K, Wei J, Hong X, Leonhart R, Zhao X, et al.
Validation of patient health questionnaire (PHQ) for major
depression in Chinese outpatients with multiple somatic
symptoms: A multicenter cross‑sectional study. J Affect Disord
2015;174:636‑43.
42. Shabbeh Z, Feizi A, Afshar H, Hassanzade Kashtali A, Adibi P.
Identifying the profiles of psychosomatic disorders in an Iranian
adult population and their relation to psychological problems.
J Mazandaran Univ Med Sci 2016;26:82‑94.
43. Bizzi F, Ensink K, Borelli JL, Mora SC, Cavanna D. Attachment
and reflective functioning in children with somatic symptom
disorders and disruptive behavior disorders. Eur Child Adolesc
Psychiatry 2019;28:705‑17.
44. Douglas H, Ginty M. The Solihull approach: Changes in health
visiting practice. Community Pract 2001;74:222‑4.
45. Meredith P, Ownsworth T, Strong J. A review of the evidence
linking adult attachment theory and chronic pain: Presenting a
conceptual model. Clin Psychol Rev 2008;28:407‑29.
46. Haas J, Eichhammer P, Traue HC, Hoffmann H, Behr M,
Crönlein T, et al. Alexithymic and somatisation scores in patients with temporomandibular pain disorder correlate with deficits in
facial emotion recognition. J Oral Rehabil 2013;40:81‑90.
47. Preis MA, Golm D, Kröner‑Herwig B, Barke A. Examining
differences in cognitive and affective theory of mind between
persons with high and low extent of somatic symptoms: An
experimental study. BMC Psychiatry 2017;17:200.