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Insecure Attachment and Hypothalamus-Pituitary-Adrenal Axis Functioning in People With Eating Disorders

Monteleone, Alessio Maria, MD; Patriciello, Giuseppina, MD; Ruzzi, Valeria, MD; Fico, Giovanna, MD; Pellegrino, Francesca, MD; Castellini, Giovanni, MD, PhD; Steardo, Luca Jr, MD; Monteleone, Palmiero, MD; Maj, Mario, MD, PhD

doi: 10.1097/PSY.0000000000000629

Objective Childhood attachment experiences affect adult emotion regulation and ability to cope with stressors. Therefore, insecure attachment may influence the functioning of the hypothalamic-pituitary-adrenal (HPA) axis and a dysregulation of HPA axis has been found in insecure attached healthy individuals. The effects of attachment on HPA axis activity have never been investigated in eating disorders (EDs). Therefore, we assessed the relationships between insecure attachment and the cortisol awakening response (CAR) in adults with EDs.

Methods Seventy-eight patients with EDs (43 with anorexia nervosa, 35 with bulimia nervosa) were recruited. They completed the Experience in Close Relationships questionnaire, which provides a rating of two insecure attachment dimensions (anxiety and avoidance) and collected saliva samples to measure the CAR. Differences in the CAR between groups with high and low attachment anxiety and between groups with high and low attachment avoidance were evaluated by repeated measures two-way analysis of variance.

Results Patients with high attachment anxiety showed a reduced CAR compared with those with low attachment anxiety (F1,76 = 7.31, p = .008). The CAR did not differ between the groups with high and low attachment avoidance (F1,76 = 0.01, p = .93). Patients with high levels of insecure attachment showed a more severe eating-related psychopathology.

Conclusions Our data show, for the first time, a specific association of the anxious attachment with the HPA axis activity in EDs and suggest a possible role of attachment in the biological vulnerability to stress of adult patients with EDs.

From the Department of Psychiatry (Monteleone, Patriciello, Ruzzi, Fico, Pellegrino, Steardo, Maj), University of Campania “Luigi Vanvitelli”, Naples; Psychiatric Unit (Castellini), Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence; and Department of Medicine (Monteleone), Surgery and Dentistry ‘Scuola Medica Salernitana,’ Section of Neurosciences, University of Salerno, Italy.

Address correspondence to Alessio Maria Monteleone, MD, Department of Psychiatry, University of Campania “Luigi Vanvitelli,” Largo Madonna delle Grazie, 80138 Napoli, Italy. E-mail:

Supplemental Content

Received for publication March 23, 2018; revision received June 21, 2018.

Copyright © 2018 by American Psychosomatic Society
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