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Attachment Theory: A Model for Health Care Utilization and Somatization

Ciechanowski, Paul S. MD, MPH; Walker, Edward A. MD; Katon, Wayne J. MD, and; Russo, Joan E. PhD

Original Articles

Objective Attachment theory proposes that cognitive schemas based on earlier repeated experiences with caregivers influence how individuals perceive and act within interpersonal relationships. We hypothesized that medical patients with two types of insecure attachment—preoccupied and fearful attachment—would have higher physical symptom reporting compared with those with other attachment styles, but that preoccupied attachment would be associated with higher and fearful attachment with lower primary care utilization and costs.

Methods In a large sample of adult female primary care health maintenance organization patients (N = 701), we used analysis of covariance and Poisson regressions to determine whether attachment style was significantly associated with 1) symptom reporting based on questions from the somatization section of the Diagnostic Interview Schedule and 2) contemporaneous automated utilization and cost data.

Results Attachment style was significantly associated with symptom reporting (p = .02), with patients with preoccupied (p = .03) and fearful (p = .003) attachment having a significantly greater number of physical symptoms compared with secure patients. There were no significant differences in medical comorbidity between attachment groups. Attachment was also significantly associated with primary care visits and costs. Patients with preoccupied attachment had the highest primary care costs and utilization, whereas patients with fearful attachment had the lowest.

Conclusions These results suggest that attachment style is an important factor in assessing symptom perception and health care utilization. Despite being on opposite ends of the utilization spectrum, patients with preoccupied and fearful attachment have the highest symptom reporting. These data challenge the observation that increased symptom reporting is uniformly associated with increased utilization in medical patients.

From the Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA.

Received for publication August 28, 2000; revision received September 7, 2001.

Address reprint requests to: Paul Ciechanowski, MD, MPH, Box 356560, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195. Email:

Copyright © 2002 by American Psychosomatic Society
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