[Downloaded free from http://www.jehp.net on Wednesday, July 7, 2021, IP: 188.87.137.

166]

Original Article

Access this article online

Quick Response Code:
Modeling the relationship between
attachment styles and somatic
symptoms with the mediating role of
emotional processing
Website:
www.jehp.net Mozhgan Falahatdoost, Behrouz Dolatshahi1, Abbas Pourshahbaz,
DOI:
Mahmoud Dehghani2, Mohsen Nouri Yalguzaghaji, Zahra Mohammadi2
10.4103/jehp.jehp_102_20

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.
Department of Clinical
CONCLUSION: Our results showed that when the reciprocal effects of attachment styles were
Psychology, University
controlled, secure attachment could be considered as a protective factor against deficits in emotional
of Social Welfare and
processing and somatization of negative emotions. On the other hand, we found that when the
Rehabilitation Sciences,
dominant attachment style in individuals was anxiety based, it could be possible that they experience
1
Department of Clinical
deficiency in the processing of emotion and more severe somatic symptoms.
Psychology, Substance
Abuse and Dependence Keywords:
Research Center, Attachment, emotional processing, somatic symptoms
University of Social
Welfare and Rehabilitation
Sciences, 2Department
of Clinical Psychology,
Introduction of these disorders.[2] Patients with somatic
symptoms tend to detach from their emotions
Iran University of Medical
Sciences, Tehran, Iran

Address for
S omatic symptom disorder is defined by
physical disturbances impairing one’s
daily functioning. [1] These disturbances
by not engaging with conscious components
of emotions (cognitive‑behavioral)
when facing with negative inputs such
correspondence: generally occur along with malicious as stress. [3‑5] In this regard, deficits in
Dr. Behrouz Dolatshahi,
thoughts, emotions, behaviors, or symbolic representation of emotion, such
Department of Clinical
Psychology, Substance health‑related concerns, and consequently, as limitations in emotional awareness and
Abuse and Dependence psychological factors play a critical role in inability to explain and respond to emotions,
Research Center, the formation, development, and treatment are typical characteristics of individuals
University of Social
Welfare and Rehabilitation This is an open access journal, and articles are
Sciences, Tehran, Iran. distributed under the terms of the Creative Commons How to cite this article: Falahatdoost M, Dolatshahi B,
E‑mail:  Dolatshahee@ Attribution‑NonCommercial‑ShareAlike 4.0 License, which Pourshahbaz A, Dehghani M, Yalguzaghaji MN,
yahoo.com allows others to remix, tweak, and build upon the work Mohammadi Z. Modeling the relationship between
non‑commercially, as long as appropriate credit is given and attachment styles and somatic symptoms with the
Received: 30‑01‑2020 the new creations are licensed under the identical terms. mediating role of emotional processing. J Edu Health
Accepted: 09‑03‑2020 Promot 2020;9:157.
Published: 30-06-2020 For reprints contact: reprints@medknow.com

© 2020 Journal of Education and Health Promotion | Published by Wolters Kluwer - Medknow 1
[Downloaded free from http://www.jehp.net on Wednesday, July 7, 2021, IP: 188.87.137.166]

Falahatdoost, et al.: Modeling the relationship between attachment styles and somatic symptoms

with somatic symptoms.[3,6,7] In other words, it seems A research by Kotler et al.[22] supports the hypothesis
that the emotion processing in people with somatic that insecure attachment is highly correlated with
symptoms is impaired. According to Baker’s theory, dysfunctional emotion processing and affects regulation
emotional processing can be seen as a three‑step process: strategies such as repression, self‑blame, and wishful
(1) identifying the emotional significance of a stimulus, thinking.[15] These variables are associated with negative
(2) creating an emotional state, and (3) emotion or health outcomes. In addition, Marganska et al.[23] found
affection regulation. Failure in any of the above steps can that emotion dysregulation is an important mediator
lead to disruption of the emotional processing.[8] in the relationship between attachment styles and
symptoms of depression and generalized anxiety in
On the other hand, emotional processing has an students. Besides, the decline in emotional awareness
important place in attachment theory. All sorts of co‑occurs with problems related to the differentiation
attachment are formed by the pattern of parent–child of physical emotions and the separation of emotional
interaction. In the process of interacting with caregivers, arousal and somatic symptoms.[3,24,25] Recent studies
the infant internalizes specific cognitive and emotional have shown that patients with medically unexplained
responses named internal working model. Bowlby physical symptoms are unable to relate their emotions
used the term internal working model to designate a to physical complaints and misinterpret the physical
cognitive framework comprising mental representations aspects of emotional arousal as somatic symptoms.[3,24]
for understanding the world, self and others. This model
which will be the basis of all future interactions with Moreover, inability to understand and express emotions
others and formation of his or her attachment type, and is associated with immune system changes and negative
has a particular role in processing emotional situations impacts on health and has been considered as a risk
and acquiring emotional responses.[9,10] In other words, factor for psychosomatic disorders and stress‑related
the process of normal emotional processing in the face illnesses.[26,27] Difficulties in identifying and expressing
of stressful situations requires the search for safe sources emotions are associated with many physical health
as real or internalized patterns of attachment.[11] Various problems such as inflammatory bowel disease, chronic
studies have not only demonstrated the existence of a back pain, physical pain disorder, and tension headaches.
difficult transition period such as high levels of emotional There are also numerous studies emphasizing the
abuse and neglect[12] in patients with somatic symptoms impairment of emotional systems in somatic symptom
but also identified the presence of insecure attachment disorder. These studies have shown cases of catastrophic
in these patients as a general symptom.[13] West et al.[14] and rumination,[28] emotional repression,[29,30] inability to
have pointed out three major mechanisms in this regard; positively regulate emotion,[31] imbalance in emotional
first, attachment insecurity can increase nonspecific arousal,[32] impaired ability in emotional awareness,[3,33]
vulnerability to stress that predicts the likelihood of and impaired emotional regulation[4] in individuals with
experiencing somatic symptoms; second, it reduces somatic symptoms. However, the important point is, in
access to support by creating a negative impact on terms of health, what are the differences and similarities
one’s ability to form and effectively use social support between the two types of insecure attachment.[15] For
networks, and ultimately, it influences the way of example, Kotler et al. [22] reported that people with
assessing emotional situations and providing emotional avoidant attachment style use more types of ineffective
response  (emotional processing) in individuals in the emotional control  (repression), which is related to
face of life circumstances.[15] emotion‑focused coping strategies. These variables
are, in fact, associated with negative psychological and
Reviewing the past studies illustrates the theoretical physical symptoms.[15]
confirmation of this model in explaining the relationship
between attachment style and health‑related In addition, other studies have indicated that avoidant
problems.[16‑18] attachment is associated with malfunctioning of the
immune system. In a different way, Feeney and Ryne
In fact, although emotion regulation and attachment have shown that anxious attachment is more related
dimensions have distinct structures, attachment patterns to health concerns and somatic symptoms.[15] Nielsen
can be characterized by specific regulatory strategies. et al.[34] considered attachment patterns as a predictor
Thus, insecure attachment may play a role in emotion of anxiety symptoms. They contended that when both
regulation problems, and these problems may have avoidant and anxious attachments were controlled, only
negative outcomes for physical and psychological anxious attachment predicted symptom severity. In
health.[19,20] In other words, emotion regulation problems addition, Stanton and Campbell[35] revealed that anxious
or other sorts of dysfunctional emotion regulation can and avoidant attachments were associated with negative
potentially play a mediating role in the relationship health outcomes, but anxious attachment compared to
between attachment types and health‑related problems.[21] avoidant attachment had a stronger and more significant
2 Journal of Education and Health Promotion | Volume 9 | June 2020
[Downloaded free from http://www.jehp.net on Wednesday, July 7, 2021, IP: 188.87.137.166]

Falahatdoost, et al.: Modeling the relationship between attachment styles and somatic symptoms

relationship with somatic symptoms. In the study by

Rapza et al., anxious and avoidant attachments were
associated with lower levels of social support, but only
anxious attachment was related with more somatic and
psychological symptoms.[15]

It should be noted that the most important issue that

explains the necessity of this research is the paradoxical
situation that this problem creates for individuals who
suffered from somatic symptoms. These patients have
a great complaint about somatic problems which are
referred to various specialists in the field of physical health Figure 1: Conceptual model for severity of somatic symptoms
that it costs a great deal for the public health system. As
the main purpose of the study, conceptualizing somatic considered for conducting the research project. Finally, in
symptom‑related problems through developmental the last step, 229 participants were selected from peoples
variables, such as attachment styles, and dynamic that came to the center by available sampling.
processes associated with emotional processing, will
have two implications for enhancing public health: (1) It should be noted that the investigators considered the
promoting educational perspectives, based on secure exclusion criteria related to comorbidities that could bias
attachment style formation, at the primary prevention the results (addiction to alcohol, drug addiction, brain
level of somatic problems, and  (2) adopt effective injury, a history of severe psychological disorder such
psychological interventions to coping with this type as psychosis or bipolar disorder, current treatment with
of issues. Furthermore, despite some research on the antipsychotic or opioid drugs).   based on self‑report,
moderating role of emotion regulation in the relationship Among the participants, anyone who met at least one of
between attachment styles and the severity of somatic the above criteria was excluded from the study.
symptoms, few studies have been conducted on the
moderating role of emotional processing as a more After obtaining the required permissions to study from
fundamental variable. As mentioned earlier, according the University of Social Welfare and Rehabilitation
to Baker’s emotional processing theory,[36] emotion Sciences and with the permission of the relevant
regulation is one of the three stages of procedure of authorities (municipality), the assistant researcher at the
emotional processing. predetermined cultural centers of each region explained
the study method to all eligible participants who came to
A review of studies suggests that although attachment the center in a certain period of time (2 weeks), assured
patterns are linked with physical and psychological them about confidentiality and anonymity of the study
health problems, there is no clear agreement on the results, and invited them to participate in the study. To
degree of impact and importance of each type of insecure carry out the research, in the first step, a brief interview
attachment styles (anxious and avoidant) and on how was conducted with each participant to determine
attachment safety affects the relationship between these inclusion and exclusion criteria. Then, in the second step,
variables. Accordingly, and as a general conclusion, from all the interviewees, all those who met the inclusion
this study seeks to answer the raised issues at two criteria and did not include the exclusion criteria entered
levels: (1) determining the extent and type of attachment the main measurement phase. For data collection, after
style with somatic symptoms experienced by individuals gathering demographic information, participants were
and  (2) examining the moderating role of emotional asked to complete all research questionnaires described
processing in the relationship between attachment in detail in the tools section.
styles and severity of somatic symptoms experienced
by individuals [Figure 1]. In this section, the measurements used in this study
are presented and information on its structural and
Materials and Methods psychometric properties is given.

This study was a descriptive‑correlational study. Two Attachment styles

hundred and twenty‑nine individuals aged 18–59 years The Collins and Reed’s Adult Attachment Scale
living in Tehran who had a full understanding of writing was employed to measure attachment styles. The
content and writing ability were selected from the general questionnaire consists of 18 items in which the individual,
population. For this purpose, 6 districts from 22 districts through self‑report, provides a graded assessment of his
of Tehran were selected randomly (districts 2, 6, 9, 14, or her skills in forming relationships.[37] The items on
17, and 21). Then, 2 cultural centers of each district were this scale are rated on a 5‑point Likert scale ranging
Journal of Education and Health Promotion | Volume 9 | June 2020 3
[Downloaded free from http://www.jehp.net on Wednesday, July 7, 2021, IP: 188.87.137.166]

Falahatdoost, et al.: Modeling the relationship between attachment styles and somatic symptoms

from 1 (not at all to my character) to 5 (completely to attachment, ambivalent attachment, and avoidant
my character). Regarding the reliability of the Adult attachment), mediator variable (emotional processing),
Attachment Scale, Collins and Reed) 1996. calculated the and endogenous variable  (somatic symptom severity)
Cronbach’s alpha for each subscale of secure, anxious, show appropriate fit or not and whether the hypothesized
and avoidant above 0.80 indicating good reliability of this relationships can be proposed as a conceptual model? To
scale. On the other hand, in Pakdaman study, the validity estimate to what extent the covariance/correlation matrix
of the measurement by applying the test–retest reliability of the assumed model fits the actual or observed data
method on 100 people with a time interval of 1 month covariance/correlation matrix, we used the Chi‑square
indicated that the test–retest value was as high as 0.95. test fit indices, Goodness of Fit Index (GFI), Root Mean
Square Error of Approximation (RMSEA), Normed Fit
Emotional processing Index (NFI), and Confirmatory Fit Index (CFI). As it is
The Emotional Processing Scale was used to assess known, RMSEA < 0.10, GFI > 0.09, CFI > 0.95, and NFI
emotional processing in this study. This scale is a 38‑item > 0.95 and 0.10>  indicates proper fit of the assumed
self‑report measurement used to measure emotional model to the actual values.
processing styles. Each item is rated on a 5‑point Likert
scale  (from strongly agree to strongly disagree). The The authors of this study, by attempting to adhere to
scale has eight components of intrusion, repression, lack ethical codes, have attempted to avoid the process and
of attunement, uncontrolled, dissociation, avoidance, results of this study being harmful to the individual
discordant, and externalized. Cronbach’s alpha and or group of persons associated with the research. The
test–retest coefficients for this scale were reported to authors believe that the results emerged from this study
be 0.92 and 0.79, respectively. In a preliminary study of could lead to a better understanding and awareness of
40 students, Lotfi calculated the correlation coefficient somatic symptoms and thus are scientific beneficial.
of this scale with the Emotion Regulation Scale to The findings of this study can eventuate in appropriate
determine the validity (r = 0.54, P < 0.01). Cronbach’s applied results for both diagnosis and employing
alpha coefficient was reported as 0.95 in another study.[34] effective therapeutic approaches in treating somatic
symptoms. Finally, the participants in this study have
Severity of somatic symptoms signed an informed consent form to participate in it.
To assess the severity of somatic symptoms, the Patient This research was done with the ethics code (IR.USWR.
Health Questionnaire  (PHQ) was used, which is a REC.1396.248) received from the Ethics Committee of the
15‑item questionnaire to measure the severity of somatic University of Social Welfare and Rehabilitation Sciences.
symptoms. Participants are asked to rate the severity
of each of the symptoms in the past 4 weeks. By giving Results
a rating between 0 and 2 to each item, the respondent
indicates the severity of each somatic symptom. Characteristics of the population studied
A score higher than or equal to 5 indicates mild somatic The total number of initial participants in this study was
symptoms, a score equal to or greater than 10 indicates 250, which was lowered to 229 due to the elimination
moderate symptoms, and a score equal to or higher than of incomplete questionnaires, random responses,
15 indicates severe symptoms.[38,39] Good psychometric or identical patterns of response. One hundred and
properties of the PHQ‑15 have been shown in various forty  (61.13%) were female and 89  (38.87%) of them
studies. In addition, a Cronbach’s alpha of 0.79 has been were male. The mean age of all participants was
reported for the questionnaire.[40] PHQ‑15 has shown 26.58  ±  9.56  years. The majority of the participants,
good internal consistency. Its positive correlations with i.e., 165  (72.05%), were married and only 64  (27.95%)
the 12‑item General Health Questionnaire and the Beck were single. Ninety‑four  (41.04%) had a high school
Depression Inventory have indicated its validity. The diploma or lower, 99  (43.23%) had a bachelor degree,
validity of its Korean version for assessing somatic and 36  (15.72%) had a master or doctorate degree. Of
symptom severity in the psychiatric outpatient settings all the participants, only 28  (12.22%) had a history of
has also been demonstrated.[41] Research results in medical diagnosis  (such as surgery, low back pain,
Iran show that the validity of the questionnaire using stomachache, and eye surgery). As an additional finding,
Cronbach’s alpha is 0.92, as well as its sensitivity and the results of the independent group t‑test showed
specificity are 73.80% and 76.20%, respectively.[42] that the somatic symptom severity experienced by
women (mean: 9.09 ± 4.84) was significantly higher than
The conceptual model presented in this study [Figure 1] the male’s symptom severity (mean: 7.29 ± 4.97; t = 2.714,
was tested with path analysis approach, using  A. P < 0.01), and it seems that the gender affects the severity
(IBM company, Armonk, New York 10504‑1722, US).This of the somatic symptoms experienced, that is, women
approach allows us to evaluate whether the hypothesized experience more somatic symptoms than men, and
relationships between exogenous variables  (secure that the severity of the experience is greater in women
4 Journal of Education and Health Promotion | Volume 9 | June 2020
[Downloaded free from http://www.jehp.net on Wednesday, July 7, 2021, IP: 188.87.137.166]

Falahatdoost, et al.: Modeling the relationship between attachment styles and somatic symptoms

than men. However, there was no significant difference observed model. Besides, checking the other absolute and
between males and females in attachment  (secure, relative indices also shows a very good fit of the model.
anxious, and avoidant) and emotion processing.
Furthermore, levels of attachment, emotional processing, Taking into account the mediating role of the emotional
and severity of somatic symptoms were not significantly processing, the standard direct effect of each of the
different based on other demographic variables such as anxious, avoidant, and secure attachments on the
education level and marital status. emotional processing variable was 0.635, −0.023, and
0.036, respectively. Standard coefficients of direct effect
Table 1 contains the correlation coefficients between the of anxious attachment, avoidant attachment, and secure
variables present in the proposed model. The results attachment on the severity of somatic symptoms were
indicated that among the three types of attachment 0.156, 0.000, and  −  0.289, respectively. In addition,
styles (secure, avoidant, and anxious), anxious attachment the coefficients of indirect effect of anxious, avoidant,
had a positive and significant relationship with deficit in and secure attachments on the severity of somatic
emotional processing and severity of somatic symptoms. symptoms were  −0.168, 0.006, and 0.011, in turn.
On the other side, secure and avoidant attachment styles Finally, the standardized overall effect coefficients of
demonstrated a negative and significant relationship the independent and mediating variables on the severity
with deficits in emotional processing and severity of of somatic symptoms in the observed model were as
somatic symptoms. follows: anxious attachment (0.324) avoidant attachment
(−0.006), secure attachment  (−0.280), and emotional
Next, in order to determine the mediating role of processing (0.265).
emotional processing in the relationship between
attachment styles  (secure, avoidant, and anxious) and Discussion
the severity of somatic symptoms, the conceptual model
discussed in the introduction section was tested using The data of this study, in line with the conceptual model,
path analysis through EMOS. It should be noted that due showed that the weakness in emotional processing had
to the weak correlation between avoidant attachment a significant effect on the severity of somatic symptoms.
and somatic symptom severity, this path was removed In agreement with the findings of this study, numerous
from the analyses. Accordingly, Figure  2 contains the studies emphasize the deficit of emotional systems
results of the path analysis of the proposed model in somatic symptom disorder. [3,4,28‑31,33] In addition,
and the associated path coefficients.  The relative and the results showed that the significant relationship
absolute indices associated with the proposed model between attachment styles and emotional processing
were as follows: GFI  =  0.998, CFI  =  0.999, NFI  =  995, had direct and indirect effects on the severity of
and RMSEA  =  0.031  (² = 1.214, P  >  0.05). Given the somatic symptoms experienced by individuals, which is
Chi‑squared size  (² = 1.214; P >  0.05), it can be said consistent with previous studies asserting the mediating
that the proposed conceptual model fits well with the role of deficits in emotional regulation and processing
in the relationship between attachment styles and
Table 1: Correlations between all variables included psychological trauma.[18‑20,34] According to our findings,
in the analysis (n=229) at the level of behavioral correlation, all three types of
Variables 1 2 3 4 5 attachment styles had a significant relationship with
1. Secure attachment ‑ emotional processing and severity of somatic symptoms.
2. Avoidant attachment 0.324** ‑ However, when the reciprocal effects of attachment styles
3. Anxious attachment −0.339** −0.245** ‑ were controlled, secure attachment could be considered
4. Emotional processing −0.392** −0.234** 0.420** ‑ as a protective factor against deficits in emotional
5. Severity of body symptom −0.187** −0.167* 0.629** 0.417** ‑ processing and somatization of negative emotions
*P<0.5, **P<0.1
due to its ability to predict negatively in relation to
the severity of somatic symptoms. Various studies
have shown the protective role of secure attachment in
psychopathology.[43,44] 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. In fact, participants who reported
higher levels of anxious attachment were more likely
to have difficulty in processing emotional information
and consequently to experience more severe somatic
Figure 2: Cross‑section path analysis model symptoms. Thus, as Subic‑Wrana et al. have proposed
Journal of Education and Health Promotion | Volume 9 | June 2020 5
[Downloaded free from http://www.jehp.net on Wednesday, July 7, 2021, IP: 188.87.137.166]

Falahatdoost, et al.: Modeling the relationship between attachment styles and somatic symptoms

based on a combination of neurobiological findings on the recommended sample size for structural
and cognitive evolution theory, it can be concluded equation modeling, and the discussion on this topic
that attachment is one of the essential components of is still ongoing.[15] One direction for future research is
structural development in the neurobiological system to replicate the findings presented here using larger
involved in emotional processing, stress balance, and sample sizes.
self‑regulation and is effective in shaping the body’s
implicit awareness. In other words, it seems that deep Conclusion
and common emotional communication can lead to an
organized relationship between the psychological and To summarize, our results support the notion that
biological domains of the person. Hence, attachment (1) different dimensions of insecure attachment can
theory can essentially be regarded as a regulatory have differential consequences for physical health and
theory. In support of this, there is evidence showing (2) emotional processing can be one of the mechanisms
that individuals with high levels of anxious attachment that explain the links between attachment and health. The
tend to catastrophize the symptoms such as pain results of the study lead to reflections on the therapeutic
and use overemphasizing the negative body‑related process, psychological change, and improved well‑being.
emotions as a pattern for forming and keeping Directly observing the physical effects of emotional
relationships. Moreover, high sensitivity and vigilance experiencing in somatic symptoms provides sensory
can make these individuals more prone to overestimate evidence that can enable patients to make mind‑body
somatic symptoms.[45] In fact, these individuals tend to connections and therapists’ ability to identify, address,
detach from their emotions by not engaging with the and utilize emotion processes.
cognitive‑behavioral components of emotion while
facing with negative inputs such as stress.[3‑5] In this Practical suggestion
regard, defects in symbolic representation of emotions Based on the results of this study, it can be suggested
such as limitations in emotional awareness and inability that the use of deeper therapeutic approaches based
to explain and respond to emotions  (alexithymia) are on the modification of emotional experience during
prominent features in somatic symptoms.[3,6] Losing psychotherapy, such as emotion‑focused therapy or
the capacity of consciously experiencing and not dynamic interpersonal therapy, can have a profound and
differentiating emotions and expressing them in a healthy long‑lasting effect on reducing the severity of somatic
way leads to a distinct pattern of emotion regulation symptoms experienced by people with somatic symptom
in these individuals characterized by heterogeneity disorder.
of emotional components in emotion processing and
difficulty in mental representation of emotional states.[46] Acknowledgment
Individuals with a higher degree of somatization have We appreciate the University of Social Welfare and
deficiencies in associating the physical experience of Rehabilitation Sciences, municipality, and all the
emotion with conscious emotions.[3,47] Failure in the participants of the research.
psychological representation of emotions can lead to
an expressing of physical emotion without conscious Financial support and sponsorship
experience of them at the psychological level. These Nil.
people usually do not experience emotional arousal at
the cognitive level but at the physical level. Conflicts of interest
There are no conflicts of interest.
The present study had some limitations that suggest
directions for future research. The most important References
limitation of this study is its cross‑sectional character. 1. Association  AP. Diagnostic and Statistical Manual of Mental
This type of research certainly cannot be an ideal way Disorders  (DSM‑5 ®). Arlington, VA: American Psychiatric
to establish causality between different variables. Publishing; 2013.
Although path models include directional effects, path 2. Sattel  H, Lahmann  C, Gündel H, Guthrie  E, Kruse  J,
analysis cannot determine causal relationships between Noll‑Hussong  M, et al. Brief psychodynamic interpersonal
psychotherapy for patients with multisomatoform disorder:
variables by itself. Furthermore, the data in this study Randomised controlled trial. Br J Psychiatry 2012;200:60‑7.
are based on self‑report measures. This might have led 3. Subic‑Wrana C, Beutel ME, Knebel A, Lane RD. Theory of mind
to faking good, especially in emotional processing. For and emotional awareness deficits in patients with somatoform
future studies, it would be beneficial to use emotional disorders. Psychosom Med 2010;72:404‑11.
induce methods and measure emotional processing 4. Beck T, Breuss M, Kumnig M, Schüßler G. The first step is the
hardest ‑ emotion recognition in patients with somatoform
directly in the real emotional status. Moreover, our disorders. Z Psychosom Med Psychother 2013;59:385‑90.
analysis is based on a study with sample size of around 5. Castelli  L, De Santis  F, De Giorgi  I, Deregibus  A, Tesio  V,
200 participants (n = 229). There is still little consensus Leombruni P, et al. Alexithymia, anger and psychological distress

6 Journal of Education and Health Promotion | Volume 9 | June 2020

[Downloaded free from http://www.jehp.net on Wednesday, July 7, 2021, IP: 188.87.137.166]

Falahatdoost, et al.: Modeling the relationship between attachment styles and somatic symptoms

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

Journal of Education and Health Promotion | Volume 9 | June 2020 7

[Downloaded free from http://www.jehp.net on Wednesday, July 7, 2021, IP: 188.87.137.166]

Falahatdoost, et al.: Modeling the relationship between attachment styles and somatic symptoms

with temporomandibular pain disorder correlate with deficits in differences in cognitive and affective theory of mind between
facial emotion recognition. J Oral Rehabil 2013;40:81‑90. persons with high and low extent of somatic symptoms: An
47. Preis  MA, Golm  D, Kröner‑Herwig  B, Barke  A. Examining experimental study. BMC Psychiatry 2017;17:200.

8 Journal of Education and Health Promotion | Volume 9 | June 2020