A controlled study of attachment representations and emotion regulation in female adolescents with anorexia nervosa

Cecilia Serena Pace, Valentina Guiducci, Donatella Cavanna


Background: Several recent studies highlighted that both attachment insecurity and emotion regulation difficulties form a key part of conceptual models of anorexia nervosa (AN), but they had never been analyzed in the same controlled study. Method: This study examined the attachment states of mind, assessed by the Adult Attachment Interview (AAI), and emotion regulation difficulties, measured by the Difficulties in Emotion Regulation Scale (DERS), among 25 girls with AN diagnosis aged 14-18 years (M age=16.52, SD= 1.23), and 25 general population controls, matched for gender, age, years of education and SES. Results. The AN group reported both significantly higher attachment insecurity (75% vs 46%, Fisher Exact Test, p=.04), dismissing (Ds) in particular (χ²=6.41, df=2, p=.03), and difficulties with emotion regulation than non-clinical controls. Two AAI’s scales connected to Ds classification – idealization of mother and lack of recall – were significantly correlated to lack of emotional awareness and clarity. Conclusions. Our results provide support for conceptualization of AN emphasizing the role of attachment insecurity and emotional dysregulation in the development and maintenance of this restrictive type of eating disorder. These findings may have implications for treatment programs which may prove more fruitful integrating attachment-based intervention with clinical work focused on development of emotion regulation abilities.



Anorexia nervosa; Attachment; Emotion regulation; Adolescence; Eating disorders

Full Text:



Aldao, A., Nolen-Hoeksema, S., Schweizer, S. (2010). Emotion-regulation strategies across psychopathology: A meta-analytic review. Clinical Psychology Review. 30, 217–237.

Bakermans-Kranenburg, M. J., & van Ijzendoorn, M. H. (1993). A psychometric study of the Adult Attachment Interview: Reliability and discriminant validity. Developmental Psychology, 29, 870-879.

Bakermans-Kranenburg, M. & Van IJzendoorn, M. (2009). The first 10,000 Adult Attachment Interviews: distributions of adult attachment representations in clinical and non-clinical groups. Attachment & Human Development, 11(3), 223–263.

Barone, L., & Guiducci, V. (2009). Mental representation of attachment in eating disorder: A pilot study using the Adult Attachment Interview. Attachment and Human Development, 11(4), 405-417.

Bühren K, Schwarte R, Fluck F, et al. (2014) Comorbid psychiatric disorders in female adolescents with first-onset anorexia nervosa. European Eating Disorders Review 22(1): 39–44.

Cassibba, R., Sette, G., Bakermans-Kranenburg, M.J., and van IJzendoorn, M.H. (2013). Attachment the Italian way. European Psychology, 18, 47–58.doi:10.1027/1016- 9040/a000128

Cloitre, M., Stovall-McClough, K.C., Zorbas, P., & Charuvastra, A. (2008). Attachment organization, emotion regulation, and expectations of support in a clinical sample of women with childhood abuse histories. Journal of Traumatic Stress, 21(3), 282-289.

Cole-Detke, H. & Kobak, R. (1996). Attachment processes in eating disorder and depression. Journal of Consulting and Clinical Psychology, 64, 282-290.

Crowell, J.A., Waters, E., Treboux, D., O’Connor, E.O., Colon-Downs, C., Feider, O., Golby, B., Posada, (1996). Discriminant validity of the Adult Attachment Interview. Child Development, 67, 2584–2599.

Del Vecchio, E., Di Riso, D., Salcuni, S., Lis, A., & George C. (2014). Anorexia and attachment: dysregulated defense and pathological mourning. Frontiers in Psychology, 5: 1218. doi:10.3389/fpsyg.2014.01218.

Dias, P., Soares, I., Klein, J., Cunha, J.P.S., & Roisman, G.I. (2011). Autonomic correlates of attachment insecurity in a sample of women with eating disorders. Attachment & Human Development, Vol. 13, No. 2, March 2011, 155–167.

D'Onofrio, E., Pace, C.S., & Cavanna, D. (2015). Qualitative research in adolescent psychotherapy: Attachment and Reflective Functioning as psychotherapy’s outcomes of an adolescent with anorexia nervosa. Research in Psychotherapy: Psychopathology, Process and Outcome, 18(2), 93-101. DOI: 10-7411/RP.2015.102.

First, M.B., Spitzer, R.L., Gibbon, M., & Williams, J. B. (1994). Structured Clinical Interview for DSM- IV Axis I Disorders (SCID I). Version 2.0. New York: New York State Psychiatric Institute, Biometrics Research.

Föcker, M., Knoll, S., Hebebrand, J. (2013). Anorexia nervosa. European Child Adolescent Psychiatry, 22 (Suppl 1), 29–35. DOI 10.1007/s00787-012-0358-6.

George, C., Kaplan, N., & Main, M. (1985). The Adult Attachment Interview Protocol (3rd ed.). Unpublished manuscript, University of California, Berkeley.

Gilboa-Schechtman, E., Avnon, L., Zubery, E., Jeczmien, P. (2006). Emotional processing in eating disorders: specific impairment or general distress-related deficiency. Journal of Depression Anxiety, 23, 331–339.

Giromini, L., Velotti, P., De Campora, G., Bonalume, L., Zavattini, G.C. (2012). Cultural Adaptation of the Difficulties in Emotion Regulation Scale: Reliability and Validity of an Italian Version. Journal of Clinical Psychology, 68(9), 989-1007. doi: 10.1002/jclp21876.

Gratz, K.L., & Roemer, L. (2004). Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the Difficulties in Emotion Regulation Scale. Journal of Psychopathology Behavioural Assessment, 26, 41–54.

Harrison, A., Sullivan, S., Tchanturia, K., & Treasure, J. (2009). Emotion recognition and regulation in anorexia nervosa. Clinical Psychology & Psychotherapy, 16 (4), 348-56.

Harrison, A., Sullivan, S., Tchanturia, K., & Treasure, J. (2010). Emotional functioning in eating disorders: Attentional bias, emotion recognition and emotion regulation. Psychological Medicine, 40, 1887–1897.

Hesse, E. (2008). The Adult Attachment Interview: Protocol, method of analysis and empirical studies. In J Cassidy & PR Shaver (Eds) Handbook of attachment: Theory, research, and clinical applications, 2nd ed. (pp. 552-598) New York: Guilford Press.

Hollingshead, A. (1975). Four–factor index of social position. Unpublished Manuscript, Yale University.

Laghi F., Pompili, S. & Zanna, V. et al. (2015a). How Adolescents with Anorexia Nervosa and their parents perceive family functioning? Journal of Health Psychology. doi: 10.1177/1359105315597055.

Laghi, F., Baiocco, R., Ghezzi, E., Petrocchi, N., & Pace, C.S. (2012). La fiducia nell’attaccamento ai genitori e ai pari e i disturbi del comportamento alimentare in adolescenza. Psicologia Clinica dello Sviluppo, XVI(3), 557-578. doi: 10.1449/38839. ISSN: 1824078X.

Laghi F., Pompili S., Zanna V., et al. (2015b). Are Adolescents with Anorexia Nervosa better at reading minds? Cognitive Neuropsychiatry. DOI: 10.1080/13546805.2015.1091766;

Kucharska-Pietura, K., Nikolaou, V., Masiak, M., Treasure, J. (2004). The recognition of emotion in the faces and voice of anorexia nervosa. International Journal of Eating Disorders, 35, 42–47.

Lavender, J.M., Anderson, D.A. (2010). Contribution of emotion regulation difficulties to disordered eating and body dissatisfaction in college men. International Journal of Eating Disorders, 43, 352–357.

Main, M., Goldwyn, R., & Hesse, E. (2002). Adult Attachment Scoring and Classification System. Version 7.1. Unpublished manuscript, University of California, Berkeley.

Mazzi, F., Morosini, P., de Girolamo, G., Lussetti, M., Guaraldi, G.P. (2000) Intervista clinica strutturata per i disturbi dell’Asse I del DSM IV, versione clinica [Structured Clinical Interview for Axis I Disorders of DSM- IV, clinical version]. Firenze: Organizzazioni Speciali.

McEwen, C., & Flour,i E, (2009), Fathers’ parenting, adverse life events, and adolescents’ emotional and eating disorder symptoms: the role of emotion regulation. European Child and Adolescent Psychiatry, 18:206–216 DOI 10.1007/s00787-008-0719-3.

Pace, C.S., San Martini, P., & Zavattini, G.C. (2011). The factor structure of the Inventory of Parent and Peer Attachment (IPPA): a survey of Italian adolescents. Personality and Individual Differences, 51, 83-88. doi: 10.1016/j.paid.2011.03.006. ISSN: 0191-8869.

Pace, C.S. (2014). Assessing attachment representations among adoptees during middle childhood and adolescence with the Friend and Family Interview (FFI): clinical and research perspectives. Frontiers in Psychology, section Psychology for Clinical Settings. 5, Article 1114, 1-4. doi: 10.3389/fpsyg.2014.01114.

Pace, C.S., Cavanna, D., Guiducci, V., & Bizzi, F. (2015). When parenting fails: alexithymia and attachment states of mind in mothers of female patients with eating disorders. Frontiers in Psychology, section Psychology for Clinical Settings, 6, Article 1145, 1-11. doi: 10.3389/fpsyg.2015.01145

Pace C., Guiducci V., Cavanna D. (2016) Attachment in Eating Disordered Outpatients with and without Borderline Personality Disorder. Journal of Health Psychology, 1-11, doi: 10.1177/1359105316636951.

Preti, A, de Girolamo, G., Vilagut, G., Alonso, J., de Graaf, R., Bruffaerts, R., Demyttenaere, K., Pinto-Meza, A., Haro, J.M., Morosini, P., The ESEMeD-WMH Investigators (2009). The epidemiology of eating disorders in six European countries: Results of the ESEMeD-WMH project. Journal of Psychiatric Research, 43, 1125–1132.

Price-Evans, K. & Treasure J. (2011). The Use of Motivational Interviewing in Anorexia Nervosa. Child and Adolescent Mental Health, 16(2), 65–70.

Racine, S.E. & Wildes, J.E. (2013). Emotion Dysregulation and Symptoms of Anorexia Nervosa: The Unique Roles of Lack of Emotional Awareness and Impulse Control Difficulties when Upset. International Journal of Eating Disorders, 46,713–720.

Ramacciotti, A., Sorbello, M., Pazzagli, A., Vismara, L., Mancone, A., & Pallanti, S. (2001). Attachment processes in eating disorders. Eating and Weight Disorders, 6(3), 166–170.

Ringer, F., & Crittenden, P. (2007). Eating disorders and attachment: The effects of hidden family processes on eating disorders. European Eating Disorders Review, 15(2), 119-130.

Sim, L., & Zeman, J. (2006). The contribution of emotion regulation to body dissatisfaction and disordered eating in early adolescent girls. Journal of Youth and Adolescence, 35 (2), 219-228.

Smink, FRE, van Hoeken, D., & Hoek, H.W. (2012) Epidemiology of eating disorders: Incidence, prevalence and mortality rates. Current Psychiatry Reports 14(4): 406–414.

Steele, H., & Steele, M. (Eds.) (2008). Clinical applications of the Adult Attachment Interview. New York, NY: Guilford Press.

Swanson S, Crow SJ, Le Grange D, et al. (2011). Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry 68(7): 714–723.

Stievenart, M., Casonato, M., Muntean, A., and van de Schoot, R. (2012). The friends and family interview: measurement invariance across Belgium and Romania. European Journal of Developmental Psychology, 9, 737–743.doi:10.1080/17405629.2012. 689822.

Ward, A., Ramsay, R., Turnbull, S., Steele, M., Steele, H., & Treasure, J. (2001). Attachment in anorexia nervosa: A transgenerational perspective. British Journal of Medical Psychology, 74, 497-505.

Whiteside, U., Chen, E., Neighbors, C., Hunter, D., Lo T., & Larimer, M. (2007). Difficulties regulating emotions: do binge eaters have fewer strategies to modulate and tolerate negative affect? Eating Behaviors, 8, 162-169.

Zachrisson, H., & Kulbotten, G. (2006). Attachment in anorexia nervosa: An exploration of associations with eating disorder psychopathology and psychiatric symptoms. Eating and Weight Disorders, 11 (4), 163-70.

DOI: https://doi.org/10.6092/2282-1619/2016.4.1187


  • There are currently no refbacks.