Psychosomatics 43:206-212, June 2002
© 2002 The Academy of Psychosomatic Medicine
Association of Attachment Style to Lifetime Medically Unexplained Symptoms in Patients With Hepatitis C
Paul S. Ciechanowski, M.D., M.P.H.,
Wayne J. Katon, M.D.,
Joan E. Russo, Ph.D., and
Megan M. Dwight-Johnson, M.D., M.P.H.
Received June 5, 2001; revised October 10, 2001; revised October 29, 2001. From the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, and the Department of Psychiatry, University of Southern California, Los Angeles, CA. Address correspondence and reprint requests to Dr. Ciechanowski, Box 356560, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195. E-mail; pavelcie{at}u.washington.edu
|
ABSTRACT
|
In this study, we sought to establish whether there was an association between adult attachment style and number of medically unexplained physical symptoms in patients with hepatitis C. Thirty-two patients with hepatitis C were assessed with regard to attachment style classification, number of lifetime medically unexplained symptoms, lifetime psychiatric diagnoses, medical comorbidity, disease severity, use of interferon, and demographic characteristics. Analysis of covariance was used to compare the four attachment groups on number of lifetime medically unexplained symptoms, and Pearson correlations were used to assess the association of continuous ratings of attachment style with lifetime medically unexplained symptoms. Number of lifetime medically unexplained symptoms varied significantly as a function of attachment style group, with patients with fearful attachment reporting significantly more medically unexplained symptoms than patients with secure attachment (P < 0.01). Number of lifetime medically unexplained symptoms was positively correlated with continuous ratings of fearful attachment (r = 0.53, P < 0.01) and preoccupied attachment (r = 0.46, P < 0.01). Implications for treatment are discussed.
Key Words: Hepatitis • Symptoms
|
INTRODUCTION
|
Medically ill patients' experience of physical symptoms is frequently discordant with the degree of tissue abnormality found on objective tests or with other observable signs of illness. A variety of psychiatric and psychosocial factors have been found to be associated with either amplification or dampening of physical symptoms in such patients. For example, comorbid anxiety and depressive disorders have been associated with symptom amplification in medically ill patients.1,2, The psychological defense of denial, on the other hand, has been associated with decreased conscious awareness, or dampening, of cardiac pain and may play a role in the phenomenon of "silent myocardial ischemia." 3,4, Researchers and clinicians have also long considered early childhood experience to be important in determining how somatic experiences are interpreted as well as in modeling how and when to use the health care system. Childhood maltreatment5, and social learning experiences, such as parental modeling or reinforcement of the sick role, 6 have been implicated as precursors of symptom amplification and somatization.
Attachment theory, which explores the impact of early attachment experiences on subsequent interpersonal behavior and perceptions, may be an appropriate conceptual framework for understanding symptom perception and health behaviors as well as patterns of health care utilization in adults. An association between attachment behavior and somatization has been proposed over the past decades, 7,,8, mostly in describing increased care-seeking behavior at times of stress in individuals with anxious attachment. Only relatively recently have researchers developed reliable, valid instruments by which to measure adult attachment so that associations between various patterns of attachment and symptom perception can be tested.
Attachment theory posits that an attachment bond between child and caregiver develops, ensuring the protection and survival of the child. 9,10, Such a bond ensures proximity to a caregiver particularly when a child is faced with external or internal (bodily distress) threats or physical discomfort, and manifests itself largely through the expression of distress, which evokes help from caregivers. If, in response to such expression of distress, the child repeatedly experiences inconsistently responsive caregiving, an adaptive strategy may develop in which the child habitually amplifies the emotional response and the perceived severity of the inciting stimulus in an attempt to ensure proximity to the caregiver. On the other hand, if the child experiences consistently unresponsive and rejecting caregiving and is rebuffed for expressions of distress, a likely adaptive strategy to optimize proximity to the caregiver may be to habitually inhibit an emotional response and perceptions of the stimulus precipitating it. Adaptive patterns based on early caregiving experiences become cognitive models or "internal working models" of interpersonal responsiveness that are propagated into adulthood and throughout the life cycle. 9,
Based on John Bowlby's work9, and empirical research in infants, children, and adults, Bartholomew11,12, has developed a classification system in adults in which there are four main attachment styles: secure, and three insecure attachment styles of dismissing, preoccupied, and fearful. Although it is possible to measure the degree to which an individual is characterized by each of these attachment styles by using continuous measures of attachment, it is often more useful clinically to determine an individual's predominant attachment style. Adults with secure attachment probably experienced consistently responsive caregiving, and they are comfortable depending on, feel it is easy to get close to, and are readily comforted by others. Adults with dismissing attachment are likely to have experienced consistently unresponsive caregiving, resulting in inhibited negative emotional and, we propose, inhibited somatic experiences. They become "compulsively self-reliant," 13 and research has suggested that clinically, they may be less apt to engage in collaborative working relationships with health care providers, are more likely to be noncompliant with treatment, and are less apt to disclose information about themselves. 14,15 Individuals with preoccupied attachment likely experienced inconsistent caregiving16; they see others as reluctant to get close, worry that other people do not really care about them, and, as a result of excessive vigilance toward attachment relationships, they are often viewed by others as being overly dependent or "clingy." As adult patients, these individuals may amplify somatic sensations and be high utilizers of health care. 17 Individuals with preoccupied attachment have a greater focus on negative affect, 18 which has been shown to be correlated with subjective health complaints even in the absence of disease. 19–21 Individuals with fearful attachment share many of the characteristics of individuals with preoccupied attachment in that they desire social contact, but this desire is eventually inhibited by fear of rejection. These individuals are proposed to have had overly critical or harsh, rejecting caregiving, and as adults they are more likely to demonstrate interpersonal patterns in which they flee once a certain level of closeness is attained; that is, approach-avoidance behavior that stems from a perception of the perils of intimacy. 18 As with individuals with preoccupied attachment, they also have an increased focus on negative affect. 18
We propose that the three insecure styles of attachment (dismissing, preoccupied, and fearful) are characterized not only by inflexible interpersonal responses to distress, but also by ingrained cognitive perceptual responses to bodily symptoms, given the salience of such symptoms as stimuli for care-seeking in early development. 8 In the current study, we sought to establish whether there was an association between adult attachment style and the number of medically unexplained physical symptoms in chronically medically ill patients. Using a sample of patients with chronic hepatitis C, we hypothesized that compared with patients with secure attachment, those with preoccupied or fearful attachment would have a significantly greater number of lifetime medically unexplained symptoms, whereas patients with dismissing attachment would have a significantly lower number of such symptoms. We also predicted that within patients, greater degrees of preoccupied or fearful attachment styles would be positively correlated with number of lifetime medically unexplained symptoms, even after controlling for number of lifetime psychiatric diagnoses.
|
METHODS
|
This is a secondary analysis of data collected on a subset of patients participating in a study to examine the effects of psychiatric illness on perception of fatigue in individuals with hepatitis C. 22
Subjects
A series of patients with a diagnosis of hepatitis C evaluated in the Division of Hepatology, University of Washington Medical Center, Seattle, participated in this study. All English-speaking, 18- to 65-year-old patients evaluated between January 1997 and March 1998 were eligible to participate. The study gastroenterologists and the research nurses in the Division of Hepatology screened schedules for eligible patients, whose charts were then examined for the following exclusion criteria: terminal phase of any illness, current encephalopathy or dementia, or current psychotic or manic disorder. Eligible patients were sent approach letters, followed by a request for participation by telephone 1 week later. Of 117 eligible patients who were sent approach letters, 53 could not be reached subsequently by telephone after five attempts. Of the remaining 64 patients who were contacted, 3 (5%) agreed to participate but failed to present for interviews, 6 (9%) did not complete required self-report questionnaires, and 5 others (8%) refused to participate. A total of 50 patients (78%) were participants in the primary study, and of these, the latter consecutive 32 (50% of contacted patients) were administered additional attachment questionnaires salient to the current study.
Measures
After obtaining informed consent from the patients, two study psychiatrists (M.D. or P.C.) used the National Institute of Mental Health Diagnostic Interview Schedule, 23 a valid and reliable structured interview, to assess current and lifetime DSM-IV psychiatric diagnoses. 24 Presence of current (1-month prevalence) and lifetime major depression, dysthymia, generalized anxiety disorder, panic disorder, alcohol and drug abuse and dependence, and lifetime somatization disorder were assessed. Thirty-two percent of the patients were interviewed by telephone because of travel restrictions around the time of the interviews. This structured interview has been shown to be equally reliable for in-person and telephone interviews. 25 The structured interview includes a section screening for somatization disorder that reviews lifetime physical symptoms and utilization of health care services. For each of 37 physical symptoms, the structured interview protocol determines symptom severity and attributes each symptom to physical illness, medication, drug use, alcohol use, or psychiatric illness. Symptoms that could not be attributed to any of these domains were categorized as "medically unexplained symptoms." Based on the number of medically unexplained symptoms, a diagnosis of somatization disorder and an abridged definition of somatization were derived. 26 As opposed to the 12 medically unexplained symptoms required for a DSM-IV diagnosis of somatization disorder, the abridged somatization criteria require only 4 or more medically unexplained symptoms for men and 6 or more for women. This diagnosis has been shown to be associated with increased functional impairment and health care utilization.
The Relationship Scale Questionnaire (RSQ) and Relationship Questionnaire (RQ) 12 were used to assess attachment style either at the time of or within 1 week of the interview. The RSQ is a valid and reliable self-report instrument of 30 items rated on a 5-point Likert scale that determines attachment style of the respondents. The RQ is a valid and reliable self-report questionnaire in which four paragraphs describing different attachment categories are rated by subjects using a 7-point Likert scale. The results from the RSQ and the RQ were combined by averaging z-transformed continuous Likert-scale data for each of the attachment style domains (secure, fearful, preoccupied, and dismissing), after which a categorical attachment style could be determined for each subject based on the attachment category with the highest score. 27
To account for the severity of hepatitis C, comorbid medical illness, and possible symptoms caused by medications used to treat hepatitis C, we obtained the following data from automated or chart records: 1) Knodell score, 28 which determines the severity of hepatic disease based on a pathologic report of a liver biopsy taken within 2 years of interview; 2) overall severity of comorbid medical illness, assessed by chart audit to obtain a score from the Duke Severity of Illness Checklist29; and 3) concurrent use of interferon for hepatitis C. Self-report questions were used to assess patient demographic characteristics.
Statistical Analysis
Results were analyzed using SPSS 10.0 for Windows. Because of the small sample size and the fact that most cells in a  2 test comparing attachment style groups and dichotomous variables had expected counts less than five, Fisher's exact test was used in six paired comparisons of the four attachment style categories with respect to dichotomous demographic characteristics (gender, Caucasian race, and marital status). Analysis of variance was used to examine group differences on continuous variables. Analysis of covariance was used to examine the association of attachment style and number of medically unexplained symptoms while controlling for potential covariates from among demographic variables, hepatic disease severity, medical comorbidity, concurrent interferon use, and number of lifetime psychiatric diagnoses. Planned comparisons using analysis of covariance with the same covariates were performed in the event of a significant attachment style effect. To examine the relation between continuous measures of the four attachment styles (the degree of each attachment style in individuals' global attachment) and number of lifetime medically unexplained symptoms, we generated a 5 x 5 correlation matrix using Pearson correlations. To determine whether an association between attachment style and number of lifetime medically unexplained symptoms had unique variance independent of vulnerabilities due to psychiatric conditions, we controlled for the number of lifetime psychiatric diagnoses in a partial correlation.
|
RESULTS
|
Patient Characteristics
There were 32 subjects (18 males and 14 females) with a mean age of 45.3 ± 9.34 years. Most subjects were married (62.5%) and Caucasian (96.9%) and had a mean education level of 13.7 ± 2.4 years. There were no significant differences in age, gender, or race between participants and nonparticipants in the primary study, 22 or between study participants who were given the attachment questionnaire (N = 32) and those who were not (N = 18).
Thirty-one percent of the subjects administered the attachment instrument had one or more of the following current DSM-IV psychiatric diagnoses: major depression (19%), dysthymia (6%), generalized anxiety disorder (13%), and alcohol abuse or dependence (3%). Seventy-eight percent of the subjects had at least one lifetime DSM-IV psychiatric diagnosis: major depression (34%), dysthymia (18%), generalized anxiety disorder (41%), panic disorder (6%), panic disorder with agoraphobia (3%), alcohol abuse or dependence (56%), substance abuse or dependence (47%), and somatization disorder (2%).
Attachment Classification
Attachment style categories were distributed relatively evenly among subjects: secure (31%), dismissing (25%), preoccupied (22%), and fearful (22%). The analysis of variance results showed no significant differences among attachment categories with respect to age, education, Knodell score, and Duke Severity of Illness Scale score. There were no significant differences among attachment style categories with respect to gender or race. However, there were significant differences between subjects with preoccupied and secure attachment with regard to concurrent interferon use (0% vs. 50%, P = 0.04), and between subjects with secure and fearful attachment with regard to percentage married (90% vs. 29%, P = 0.04). Prevalence of any specific current or lifetime psychiatric diagnoses did not differ among attachment groups; however, the number of lifetime psychiatric diagnoses did differ among the four groups at a trend level (mean ± standard deviation): secure (1.4 ± 1.6), dismissing (1.8 ± 1.3), preoccupied (3.6 ± 2.1), and fearful (2.7 ± 2.1) [F(3,28) = 2.46, P = 0.08].
Medically Unexplained Symptoms
Based on the number of medically unexplained symptoms, 26 41% of the subjects met the abridged criteria for somatization. The majority of subjects with fearful attachment (57%) and preoccupied attachment (71%) met the abridged criteria for somatization, whereas only 30% of patients with secure attachment and 13% of patients with dismissing attachment met these criteria. Fisher's exact tests revealed significant differences between the dismissing and preoccupied attachment groups (P < 0.05).
Analysis of covariance was performed to determine whether there were differences among attachment categories with regard to the number of medically unexplained symptoms, after adjusting for covariates. Variables that were significantly different among attachment categories were entered as covariates (martial status, interferon use). Gender was also entered because there is a well-established association between gender and somatization. Furthermore, because of the well-established association between psychiatric diagnoses and medically unexplained symptoms, we also adjusted for number of lifetime psychiatric diagnoses. Although an argument could also be made for use of number of current psychiatric diagnoses, we decided conceptually that controlling for lifetime symptoms was a more conservative approach. The correlation between number of current and lifetime psychiatric diagnoses in this sample was high: r = 0.68, P < 0.01.
There were significant differences in the number of medically unexplained symptoms among attachment groups [F(7,24) = 5.26, P = 0.006] (Table 1). Planned comparisons between attachment categories revealed significant differences in medically unexplained symptoms between fearful and secure attachment groups [F(5,11) = 9.99, P < 0.01] and between fearful and dismissing attachment groups [F(5,9) = 5.96, P < 0.04] (Table 1). Differences between dismissing and secure [F(5,12) = 3.025, P = 0.108] and between dismissing and preoccupied attachment groups [F(5,9) = 4.292, P = 0.068] were trend level. All other comparisons were not significant.
A 5 x 5 correlation matrix (Table 2) was generated, and the results were consistent with data from the analysis of covariance using categorical groupings of attachment. There was a positive correlation between number of lifetime medically unexplained symptoms and fearful attachment (r = 0.53, P < 0.01). There was also a positive correlation between number of lifetime medically unexplained symptoms and preoccupied attachment (r = 0.46, P < 0.01). The correlations between lifetime medically unexplained symptoms and secure or dismissing attachment were much weaker and not significant. Using a partial correlation in which number of lifetime psychiatric diagnoses was adjusted for, we found that the correlation between lifetime medically unexplained symptoms and fearful attachment persisted (r = 0.40, P < 0.05), whereas the correlation between lifetime medically unexplained symptoms and preoccupied attachment did not (r = 0.26, not significant). Adjusting further for gender, marital status, and interferon use, in addition to number of lifetime psychiatric diagnoses, did not change these partial correlations.
|
DISCUSSION
|
In this study, we investigated the relation between attachment style of patients with hepatitis C and number of lifetime medically unexplained symptoms. From unadjusted data, we found that significantly more patients with preoccupied attachment met Escobar's criteria26 for somatization as compared with patients with dismissing attachment. After adjusting for lifetime number of psychiatric diagnoses, gender, marital status, and use of interferon, we found that those patients with fearful attachment had a significantly greater number of medically unexplained symptoms than patients with secure or dismissing attachment. From adjusted data, there were trend-level differences in number of medically unexplained symptoms between individuals with dismissing and preoccupied attachment and between those with dismissing and secure attachment, with individuals with dismissing attachment tending to report fewer medically unexplained symptoms in both comparisons. Within individuals, greater degrees of preoccupied and fearful attachment assessed by continuous ratings were associated with a greater number of medically unexplained symptoms.
Somatic perceptions may be altered by state (e.g., depression, anxiety) or trait (e.g., attachment style) characteristics. Research has found that individuals with insecure attachment are significantly more likely to have Axis I psychiatric diagnoses as compared with individuals with secure attachment. 30 In these analyses, we adjusted for number of lifetime psychiatric diagnoses to consider the effect of attachment style on symptom perception unmediated by Axis I psychiatric diagnoses. The significant association between preoccupied attachment and lifetime medically unexplained symptoms in our sample became nonsignificant after controlling for number of lifetime psychiatric diagnoses. Although one must interpret these results with caution, given the small sample size of the study, these results may suggest that, clinically, reporting of medically unexplained symptoms in individuals with preoccupied attachment may be related to increased vulnerability associated with Axis I psychiatric diagnoses. Our results suggest that in individuals with fearful attachment, however, reporting of medically unexplained symptoms does not appear to be significantly related to number of lifetime psychiatric disorders. Although these results are preliminary, they may indicate that successful treatment of Axis I disorders may lead to a greater decrease in the degree of symptom reporting in patients with preoccupied attachment than in those with fearful attachment.
Although much of our investigation focused on increased reporting of somatic symptoms, the trend-level difference between the secure and dismissing attachment groups suggests that dismissing attachment, as expected from theory, may be associated with inhibition or dampening of somatic symptoms. This is consistent with research showing that individuals with type C coping (or avoidant coping style, with similar characteristics as in individuals with dismissing attachment) have a tendency to ignore signals of pain and fatigue. 17,31 Although signals of distress and physical discomfort may have been habitually ignored in early development by individuals with dismissing attachment as an adaptive strategy to ensure proximity to a caregiver, such ingrained strategies may become maladaptive in the health care setting. Clinically, it is not uncommon for apparently stoic individuals who ignore medical symptoms to also be those patients who are less compliant with treatment or self-care and who are less likely to form collaborative working relationships with health care providers or other supports, thus placing these individuals at risk for advancing medical illness without appropriate health care. We have found, for example, that diabetic patients with dismissing attachment have poorer adherence to diabetes regimens, as indicated by both higher glycosylated hemoglobin levels and poorer adherence to oral hypoglycemic medications. 15 Clearly, this is an area that deserves further investigation.
In addition to having a small sample size, which was potentially biased as a result of high non-response to contact letters and telephone contacts, this study is also limited by its cross-sectional design. However, given the relative stability of the attachment behavioral system over one's lifetime, 32–35 it may be assumed that the attachment styles being measured preceded the onset of symptom reporting in these adult patients. Another limitation may be that these results may not generalize to individuals with chronic illnesses other than hepatitis C, or to individuals who are not chronically medically ill. Strengths of this study include the use of structured interviews to assess medically unexplained symptoms and to make DSM-IV diagnoses, the use of objective indices of severity of liver pathology, and the use of thorough measures of medical comorbidity derived from medical chart reviews.
Attachment theory is a novel interpersonal framework in which patients may be categorized according to a spectrum of maladaptive strategies of coping with and reporting of medical symptoms. For example, somatizers may lie on one end of the spectrum (individuals with fearful and preoccupied attachment) and patients with denial or dampening of symptoms on the other end (individuals with dismissing attachment). Understanding where a patient may appear on this attachment-somatization spectrum may help clinicians optimize diagnoses and treatment to better meet the needs of patients. For example, those patients with preoccupied attachment may benefit from more traditional approaches, such as regularly scheduled appointments with a consistent caregiver. Patients with fearful attachment, who potentially engage in the health care relationship as long as it is not too interpersonally close, may benefit from regular attention to their problems by several providers in a clinic, without an emphasis on care by a single provider, although they may eventually learn to trust a single provider. For patients with dismissing attachment, population-based approaches may be needed, such as proactive contacts by clinics or telephone calls or home visits by nurses or caseworkers, since they are less likely to use medical care appropriately because of their relative inability to collaborate with clinicians. In general, in chronically ill medical patients with dismissing attachment, clinicans may need to have a higher index of suspicion with regard to the possibility of worsening medical illness or complications, given their possible tendency to underreport symptoms.
Larger studies of medically ill patients are needed to better characterize the perceptions or reporting of symptoms among individuals with different attachment styles. Associated health-related functional status may also need to be investigated because it may differ among the types of attachment styles. Finally, we show that health-related perceptions and, in turn, health behaviors may be determined as much, or more, by the specific type of insecure attachment as by the mere presence of insecure attachment.
|
ACKNOWLEDGMENTS
|
The authors thank Kris V. Kowdley and Anne M. Larson for their significant assistance with the principal study on which this paper is based, and Deardra Rivera-Ball for her assistance in patient recruitment and data entry.
|
REFERENCES
|
-
Katon W, Sullivan M, Walker E: Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma and personality traits. Ann Intern Med 2001; 134:917-925[Abstract/Free Full Text]
-
Lipowski ZJ: Somatization: the concept and its clinical application. Am J Psychiatry 1998; 145:1358-1368[Abstract/Free Full Text]
-
Barsky AJ, Hochstrasser B, Coles NA, et al: Silent myocardial ischemia. Is the person or the event silent? JAMA 1990; 264:1132-1135[Abstract/Free Full Text]
-
Lumley M, Rowland L, Torosian T, et al: Decreased health care use among patients with silent myocardial ischemia: support for a generalized rather than a cardiac-specific silence. J Psychosom Res 2000; 48:479-484[CrossRef][Medline]
-
Walker EA, Gelfand A, Katon WJ, et al: Adult health status of women with histories of childhood abuse and neglect. Am J Med 1999; 107:332-339[CrossRef][Medline]
-
Barsky AJ, Borus JF: Functional somatic syndromes. Ann Intern Med 1999; 130:910-921[Abstract/Free Full Text]
-
Kolb LC: Attachment behavior and pain complaints. Psychosomatics 1982; 23:413-425[Free Full Text]
-
Stuart S, Noyes R Jr: Attachment and interpersonal communication in somatization. Psychosomatics 1999; 40:34-43[Abstract/Free Full Text]
-
Bowlby J: Attachment and Loss: Volume II. Separation: Anxiety and Anger. New York, Basic Books, 1973
-
Fonagy P: An attachment theory approach to treatment of the difficult patient. Bull Menninger Clin 1998; 62:147-169[Medline]
-
Bartholomew K, Horowitz LM: Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol 1991; 61:226-244[CrossRef][Medline]
-
Griffin DW, Bartholomew K: The metaphysics of measurement: the case of adult attachment. Advances in Personal Relationships 1994; 5:17-52
-
Bowlby J: The making and breaking of affectional bonds: Br J Psychiatry 1977; 130:201-210
-
Dozier M: Attachment organization and treatment use for adults with serious psychopathological disorders. Dev Psychopathol 1990; 2:47-60
-
Ciechanowski PS, Katon WJ, Russo JE, et al: The patient-provider relationship: attachment theory and adherence to treatment in diabetes. Am J Psychiatry 2001; 158:29-35[Abstract/Free Full Text]
-
Bartholomew K: Avoidance of intimacy: an attachment perspective. J Soc Pers Relat 1990; 7:147-178[Abstract]
-
Feeney J, Ryan S: Attachment style and affect regulation: relationships with health behavior and family experiences of illness in a student sample. Health Psychol 1994; 13:334-345[CrossRef][Medline]
-
Bartholomew K: From childhood to adult relationships: attachment theory and research, in Learning About Relationships: Understanding Relationships Processes Series, Volume 2. Edited by Duck S. Newbury Park, CA, Sage Publications, 1993
-
Russo J, Katon W, Lin E, et al: Neuroticism and extroversion as predictors of health outcomes in depressed primary care patients. Psychosomatics 1997; 38:339-348[Abstract/Free Full Text]
-
Costa PT, McCrae RR: Neuroticism, somatic complaints, and disease: is the bark worse than the bite? J Pers 1987; 55:299-316[CrossRef][Medline]
-
Watson D, Pennebaker JW: Health complaints, stress, and distress: exploring the central role of negative affectivity. Psychol Rev 1989; 96:234-254[CrossRef][Medline]
-
Dwight MD, Kowdley KV, Russo JE, et al: Depression, fatigue, and functional disability in patients with chronic hepatitis C. J Psychosom Res 2000; 49;311-317
-
Robins LN, Helzer JE, Croughan J, et al: The NIMH Diagnostic Interview Schedule. Arch Gen Psychiatry 1981; 38:381-389[Abstract/Free Full Text]
-
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC, American Psychiatric Association, 1994
-
Wells KB, Barnham MA, Leahe B, et al: Agreement between face to face and telephone administered versions of the depression section of the NIMH diagnostic interview schedule. J Psychiatr Res 1988; 22:207-220[CrossRef][Medline]
-
Escobar JI, Burnam A, Karno M, et al: Somatization in the community. Arch Gen Psychiatry 1987; 44:713-718[Abstract/Free Full Text]
-
Ognibene TC, Collins NL: Adult attachment styles, perceived social support and coping strategies. J Soc Pers Relat 1998; 15:323-345[Abstract]
-
Knodell RG, Ishak KG, Black WC, et al: Formulation and application of a numerical scoring system for assessing histological activity in asymptomatic chronic active hepatitis. Hepatology 1981; 1:431-435[Medline]
-
Parkerson GR Jr, Broadhead WE, Tse CK: The Duke Severity of Illness Checklist (DUSOI) for measurement of severity and comorbidity. J Clin Epidemiol 1993; 46:379-393[CrossRef][Medline]
-
Mickelson KD, Kessler RC, Shaver PR: Adult attachment in a nationally representative sample. J Pers Soc Psychol 1997; 73:1092-1106[CrossRef][Medline]
-
Temoshok LR: Complex coping patterns and their role in adaptation and neuroimmunomodulation: theory, methodology, and research, in Neuroimmunomodulation: Perspectives at the New Millennium. Annals of the New York Academy of Sciences, Volume 917. Edited by Conti A, Maestroni GJM, et al. New York, New York Academy of Sciences, 2000, pp 446-455
-
Kirkpatrick LA, Hazan C: Attachment styles and close relationships: a four-year prospective study. Personal Relationships 1994; 1:123-142
-
Hamilton CE: Continuity and discontinuity of attachment from infancy through adolescence. Child Dev 2000; 71:690-694[CrossRef][Medline]
-
Waters E, Merrick SK, Treboux D, et al: Attachment security in infancy and early adulthood: a twenty-year longitudinal study. Child Dev 2000; 71:684-689[CrossRef][Medline]
-
Klohnen EC, Oliver JP: Working models of attachment: a theory-based prototype approach, in Attachment Theory and Close Relationships. Edited by Simpson JA, Rholes WS. New York, Guilford Press, 1998, pp 115-140
This article has been cited by other articles:
|
|
|
|
 
A. Tan, C. Zimmermann, and G. Rodin
Interpersonal processes in palliative care: an attachment perspective on the patient-clinician relationship
Palliative Medicine,
March 1, 2005;
19(2):
143 - 150.
[Abstract]
[PDF]
|
|
|
|
|
|
|
D. Thompson and P. S. Ciechanowski
Attaching a New Understanding to the Patient-Physician Relationship in Family Practice
J Am Board Fam Med,
May 1, 2003;
16(3):
219 - 226.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. S. Ciechanowski, E. A. Walker, W. J. Katon, and J. E. Russo
Attachment Theory: A Model for Health Care Utilization and Somatization
Psychosom Med,
July 1, 2002;
64(4):
660 - 667.
[Abstract]
[Full Text]
[PDF]
|
|
|
Get information about faster international access.
Privacy Policy
Copyright © 2002
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
INTRODUCTION
