Struggling with an eating disorder can be related to many aspects of an individual’s life, but can it be associated with attachment style? A study published in the International Journal of Eating Disorders explores the existing literature suggesting that people with eating disorders tend to have high levels of insecure attachment styles.
Eating disorders are especially debilitating mental illnesses that are associated with high levels of medical disability and mortality. Attachment style has been a subject of interest in regard to eating disorders, as it has been theorized that early caretaker interaction could be causative to developing eating disorders.
Anxious and avoidant attachment styles are two patterns of insecure behavior and emotional responses that individuals may develop in close relationships. These styles reflect different strategies people adopt to navigate emotional intimacy and seek security in relationships.
Anxious individuals seek constant validation and fear rejection or abandonment. They may be overly dependent and have intense emotional reactions. Avoidant individuals prioritize independence, fear intimacy, and may appear emotionally distant or unavailable. They value personal space and struggle with trust.
Attachment has also been thought to be an important consideration in treatment, as family and friends can play a key role in recovery. The new study sought to better understand the relationship between attachment and eating disorders by conducting an updated meta-analysis and including potential moderators.
In a meta-analysis, researchers collect data from various studies, analyze them collectively, and draw conclusions based on the combined results. This method allows for a larger sample size, increasing statistical power and the ability to detect patterns or trends that may not be evident in individual studies.
Tom Jewell and colleagues searched for relevant studies on several databases, including Google Scholar, PsycINFO, and others with no date restriction imposed. The researchers screened studies and inclusion criteria included having a healthy control group, confirmed diagnosis by clinicians or use of validated measures of disordered eating, and basis in attachment theory.
Studies using infantile anorexia were excluded because it is not in the DSM or ICD and studies using the Parental Bonding Instrument were also excluded due to the basis not being in attachment theory. Publication bias was assessed and estimates were adjusted accordingly.
Jewell and colleagues conducted eight meta-analyses, including attachment security assessed by interview and assessed by self-report, attachment avoidance assessed by self-report in eating disorder samples, anorexia nervosa samples and bulimia nervosa samples, and attachment anxiety assessed by self-report in eating disorder samples, in anorexia nervosa samples, and in bulimia nervosa samples.
Across all eight meta-analyses, higher rates of attachment insecurity were found in eating disorder samples. These relationships all showed moderate to large effect sizes. This study found no significant moderating effect of age, sampling, or control group matching.
Age not having a significant moderating effect may suggest that the relationship between attachment insecurity and disordered eating may not be significantly changed by developmental stage.
The one significant moderator found in this meta-analyses was blinding assessors for studies that used interviewing. While researchers expected to see larger effect sizes in studies that did not use blinding, there were actually smaller ones in many of them. Only one study used a group of people recovered from eating disorders, but that study found them to have no significant differences from the control group.
This study took important steps into better understanding the body of literature linking attachment insecurity and eating disorders. Despite this, there are limitations to note, and meta-analyses are bound by many of the limitations of the original studies. A significant limitation of this study is that they did not consider autistic spectrum disorder, despite ASD being notably raised in eating disorder populations.
Nevertheless, the findings have some important clinical implications.
“Understanding insecure attachment patterns in the therapeutic context could help clinicians to identify, or even anticipate, therapeutic ruptures, and seek to proactively repair these,” the researchers wrote. “In addition, it is possible that attachment may be a worthwhile treatment target. For instance, helping patients to understand their own attachment histories, and their current ways of responding to distress in close relationships, could play a helpful role, and would be consistent with evidence-based models such as Focal Psychodynamic Therapy.”
The study, “Attachment in individuals with eating disorders compared to community controls: A systematic review and meta-analysis“, was authored by Tom Jewell, Eleni Apostolidou, Kevser Sadikovic, Kirsty Tahta-Wraith, Sarah Liston, Mima Simic, Ivan Eisler, Peter Fonagy, and Isabel Yorke.