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Influence of Patient Attachment Style on Self-care and Outcomes in Diabetes

Ciechanowski, Paul MD, MPH; Russo, Joan PhD; Katon, Wayne MD; Von Korff, Michael ScD; Ludman, Evette PhD; Lin, Elizabeth MD, MPH; Simon, Gregory MD, MPH; Bush, Terry PhD

doi: 10.1097/01.psy.0000138125.59122.23
Original Articles

Objective: Difficulties collaborating with providers and important others may adversely influence self-management in patients with diabetes. We predicted that dismissing attachment style, characterized by high interpersonal self-reliance and low trust of others, would be associated with poorer self-management in patients with diabetes.

Methods: A population-based mail survey was sent to all patients with diabetes from nine primary care clinics of a health maintenance organization. We collected data on attachment style, self-care behaviors, the patient provider relationship and depression status and accessed automated diagnostic, pharmacy, and laboratory data to measure diabetes treatment intensity, medical comorbidity, glycosylated hemoglobin levels, and diabetes complications. We used logistic regression to determine whether dismissing attachment style was associated with poorer diabetes self-care behaviors, adherence to medication, smoking status, and higher glycosylated hemoglobin.

Results: In 4095 primary care patients with diabetes, prevalence rates for secure, dismissing, preoccupied, and fearful attachment styles were 44.2%, 35.8%, 7.9%, and 12.1%, respectively. When compared with secure attachment style, dismissing attachment style was associated with significantly lower levels of exercise (p = .005), foot care (p < .05), diet (p = .001), and adherence to oral hypoglycemic medications (p < .05), and with higher rates of smoking (p < .05), and these associations were mediated through the patient-provider relationship. Preoccupied attachment style, characterized by overreliance on others, was associated with a significantly lower risk of having glycosylated hemoglobin levels >8%, compared with secure attachment style.

Conclusion: Attachment style is significantly associated with diabetes self-management and outcomes.

HbA1c = glycosylated hemoglobin; GHC = Group Health Cooperative; BMI = body mass index; IV = independent variable; DV = dependent variable.

From the Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA (P.C., J.R., W.K.); and the Center for Health Studies, Group Health Cooperative, Seattle, WA (M.V.K., E. Ludman, E. Lin, G.S., T.B.).

Address correspondence and reprint requests to Paul Ciechanowski, MD, MPH, Department of Psychiatry and Behavioral Sciences, Box 356560, University of Washington School of Medicine, 1959 N. E. Pacific, Seattle, WA 98195-6560. E-mail:

Received for publication September 25, 2003; revision received April 28, 2004.

Supported by grants #MH 4–1739 and #MH 016473 from the National Institute of Mental Health Services Division, Bethesda, MD (Dr. Katon), and by National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) grant K23 DK60652–01 (Dr. Ciechanowski).

Copyright © 2004 by American Psychosomatic Society
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