Clinical Child Psychology and

Psychiatry
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Attachment Research and Eating Disorders: A Review of the Literature

Ruth O'Shaughnessy and Rudi Dallos
Clin Child Psychol Psychiatry 2009 14: 559
DOI: 10.1177/1359104509339082

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 Attachment Research and Eating Disorders:
A Review of the Literature

RUTH O’SHAUGHNESSY
Alder Hey Children’s NHS Foundation Trust, UK

RUDI DALLOS
University of Plymouth, UK

A B S T R AC T
The aim of this article is to review the clinical literature which examines the
association between attachment patterns and eating disorders with a focus on
anorexia nervosa, and to examine the varieties of methods and measures employed
in attachment research. A literature review was carried out and the relevant
articles are examined in terms of their contribution to this area. The literature
indicates a number of important considerations when working with this group,
including extreme separation anxiety and unresolved loss and trauma, and
discusses the implications of these findings for treatment. The results also indicate
conflicting evidence regarding associations between attachment style and eating
disorder subgroup suggesting that severity of disorder matters more than eating
disorder subtype. The different ways of investigating attachment patterns and
experiences are explored in this paper. It is suggested that the attachment classifi-
cation system runs the risk of reducing complex human experience to typologies
and that qualitative research might help to address this problem.

K E Y WO R D S
anorexia nervosa, attachment, eating disorders, literature review, qualitative

RU T H O ’ S H AU G H N E S S Y
is currently employed in an early years Child and Adolescent
Mental Health Service at Alder Hey Children’s Hospital, Liverpool. Her interests include
attachment theory and its clinical applications, infant mental health, and using collaborative
research methodologies.
C O N TA C T :
Ruth O’Shaughnessy, Working Together, Early Years CAMHS, Croxteth Gems,
Armill Road, Croxteth, Liverpool L11 4TR, UK. [E-mail: ruth.oshaughnessy@alderhey.nhs.uk]

RUDI DA L L O S is a Consultant Clinical Psychologist and Programme Director of the

University of Plymouth DClin training course. He specializes in family therapy and work with
adolescents, including young people with eating disorders.

Clinical Child Psychology and Psychiatry Copyright © The Author(s), 2009.

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Vol 14(4): 559–574. DOI: 10.1177/1359104509339082 http://ccp.sagepub.com

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 CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 14(4)

E AT I N G D I S O R D E R S , E S P E C I A L LY A N O R E X I A , have been considered from a

variety of perspectives and levels of analysis including individual (e.g. genetic, bio-
logical, personality, trauma), relational/familial (e.g. enmeshment, triangulation, conflict-
avoidant systems) and societal factors (e.g. gender/culture expectations). Although each
of these have been suggested as possible causes of eating disorders, the evidence has
been inconclusive. Attachment theory offers one comprehensive framework for under-
standing anorexia and illuminates how many of these factors contribute to the develop-
ment of this complex and painful condition. It allows clinicians to understand a range of
psychological functions including those pertinent to eating disorders, for example
emotional regulation, interpersonal functioning, and maintenance of self- esteem
(Ramacciotti et al., 2001). The aims of this article are twofold: the review will first point
to the contribution of attachment theory research in this area and will then examine the
different methods and measures employed in attachment research.
We are particularly interested in the relevance of attachment theory since its focus is
on how danger, distress and discomfort are responded to by the parents. Since food and
hunger are both one of the earliest forms of distress and anxiety, as well as pleasure for
the infant, it is helpful to explore the contribution of an attachment theory framework
(Farber, 2008). In particular we are interested in reviewing the findings regarding how
the pattern of early responses sets in motion both specific patterns relating to food and
also to attachment strategies more broadly, and in turn how these two are linked.

Historical perspective
Hilda Bruch (1973, 1978) was one of the first and most influential researchers to advocate
the function of early relationship difficulties in the development of eating disorders.
Bruch described family environments characterized by overprotection, intrusiveness,
and control, with few opportunities for self-expression. She argued that these inter-
actions led to the development of a highly compliant ‘false self’ as a defence against
parental impingement. Self-starvation was therefore understood as ‘a defence against
the feeling of not having a core personality of their own, of being powerless and in-
effective’ (Bruch, 1982, p. 1532). In effect within this framework anorexia is a form of
covert communication of protest and attempt for autonomy. Bruch suggested that
compliance becomes a means of survival, to the point where the child is unable to differ-
entiate between feeling hungry and satisfied. The difficulty in recognizing basic needs
therefore becomes emblematic of an environment characterized by an enmeshed and
intrusive mother–daughter relationship (Dalzell, 2000). Eating disorders, particularly
anorexia, were thus understood as involving the failure to successfully complete the
separation-individuation process, a developmental task that becomes particularly acute
during adolescence.
Similarly, the early family therapists described the family environments of people with
anorexia as emotionally unresponsive and overcontrolling (Palazzoli, 1978). Palazzoli
characterized these families in terms of the importance of loyalty, self-sacrifice, secret
coalitions, and poor conflict resolution between family members. Interestingly Palazzoli
also considered a gendered perspective in noting the shift for the mothers of young
women with anorexia from a rural tradition, comfortable with healthy, generous eating
and clear maternal roles of carer, provider of meals and homemaker to life in urban
settings with less emphasis on these values and more on appearance, presentation and
status through outside work. In effect, Palazzoli saw the daughters with anorexia as
expressing through their bodies the conflict that their mothers felt about being caught
between a traditional and more modern role. However, their mothers were unable or

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 O’SHAUGHNESSY: ATTACHMENT AND EATING DISORDERS

unwilling to overtly express this tension nor did they support their daughters’ indirect
expression of conflicts in relation to this. Later they came to see this conflict more as the
young women being caught between a stalemated conflict between their parents.
Systems concepts concerning anorexia nervosa have been most clearly outlined by
Minuchin, Rosman, and Baker (1978). They identified the following features as reflect-
ing the family dynamics of patients diagnosed with anorexia: Enmeshment, over-
protection, rigidity, triangulation of the child, and poor conflict resolution. These
characteristics provide the context for the child to use her illness as a means for com-
municating avoided messages as well as family and parental conflict. Minuchin and his
team understood anorexia as crucial in maintaining the family’s ‘homeostasis’, with the
child becoming her family’s critical regulator in the same way that the mother serves as
the infant’s regulatory system (Klayman-Farber, 2002). Taken together, these dynamics
are seen to prevent communication and to keep emotional needs suppressed, leading to
‘symptoms’. The young woman, unable to decipher, let alone express, what she needs or
feels begins her long and silent protest.
Though systemic perspective offered interesting clinically based observations they
have less to say about how these patterns develop in families and, importantly, how the
child’s internal world becomes constructed in such a way that self-starvation is adopted
as a way of life. Clinically it is also crucial to try to understand how this becomes such a
tenacious and central part of their identity. Once established an anorexic identity
appears to be one of the most intractable and dangerous of all clinical conditions
(e.g. Fairburn & Brownell, 2002)

Attachment theory
Bowlby and his followers underscore the significance of early relationships and later
psychological functioning. Bowlby (1969, 1973, 1980) postulated that all babies are
biologically predisposed to form attachment relationships through the evolutionary-
based instinct to seek protection, safety and comfort. The infant develops a range a
repertoire of behaviours (e.g. crying, clinging) aimed at seeking safety and closeness to
caregivers, usually the mother, when feeling threatened (e.g. psychological or physical
absence of caregiver, condition of the child, alarming environmental conditions). An
important principle of attachment theory is that the nature of the attachment is deter-
mined by the interactions between the infant and the caregiver. Caregiver sensitivity and
responsiveness to the infant’s communications’ are thought to be critical in how the
infant learns to regulate emotional experiences. For example, with responsive care-
giving the child is more likely to regulate distress using strategies to seek comfort and
support which in turn facilitates the development of a secure attachment. However, if
distress cues are met with inconsistency, insensitivity or unresponsiveness the infant will
learn to associate distress with aversive consequences and will develop strategies leading
to insecure attachment strategies (Ainsworth, Belhar, Walters, & Wally, 1978).
Mary Ainsworth et al. (1978) were the first to develop an attachment classification
system. Based on an extensive observation of infant attachment behaviour, Ainsworth
and her colleagues developed a tripartite classification of organized attachments based
on the infants’ response to a structured separation procedure – the ‘Strange Situation’.
The infants’ behavioural responses to separation were seen to represent the infants’
expectations of their attachment figures availability as well as their attachment strategy
(Brown & Wright, 2001). Group B infants (secure) were seen to be more harmonious
and co-operative in their interactions with their caregivers. A secure infant used his/her
mother as a secure base from which to explore and turned to her for comfort when

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 CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 14(4)

distressed. These mothers were seen to respond sensitively to their infants while the
infants were quickly soothed by their mothers. Group A infants (insecure-avoidant)
were seen to show little response to separation and a conspicuous avoidance of
proximity seeking or interaction with their attachment figures. Their mothers were
observed to respond in a rejecting way to their infants. Finally, group C infants (insecure-
resistant/ambivalent) responded to separation with immediate and intense distress and
were less quickly soothed by their attachment figures. Their mothers were observed to
be more intrusive and inconsistent in their responses to their infants’ communications.
A further category of ‘disorganized/disoriented attachment category (group D infants)
was later added to the classification system for those infants who were originally deemed
unclassifiable (Main & Solomon, 1990). These infants behaved in a contradictory and
incoherent way when their mothers were present and appeared to lack an organized
strategy for dealing with the stress of separation. Main and Solomon (1990) suggested
on the basis of their observations that many of the mothers of these infants displayed
‘frightened’ and/or ‘frightening’ behaviour leaving the child confused, frightened and
unable to relieve distress.
Bowlby further suggests that the early experience of attachment relationships leads
to the development of a cognitive model (internal working model) of relationships which
influences, and is influenced by, later relationships. Internal working models are pre-
dictions which the child develops about him or herself and others, and the response of
significant others to his or her attachment needs. Attachment research has also focused
on developing assessment tools for measuring attachment styles at the representational
level. For example, the Adult Attachment Interview (AAI, George, Kaplan, & Main,
1985) is a semistructured interview which aims to discern attachment style through the
analysis of narratives. Adults are asked to recall memories of childhood events and
relationship experiences which are then assessed in terms of their content, process and
coherence and categorized accordingly. The terminology for classification of the repre-
sentational strategies is: Secure/balanced, dismissive and preoccupied. These terms
match those used for classifying behaviours but refer to the style of narrating one’s
experiences, for example the importance ascribed to attachment needs rather than
observable behaviours. Research has shown that securely attached individuals are able
to give a coherent account of their childhood experiences and relationships, including
those which were considered distressing. Individuals whose accounts are classified as
‘dismissive’ on the AAI, give clear and logical accounts but appear to find it difficult to
recall detailed memories of events, have a tendency to idealize the past and to take
excessive responsibility for events. In contrast the those classified as preoccupied on the
AAI appear in their accounts to be emotionally preoccupied and entangled with events
in the past, they tend to simplify the complexity of relationships by blaming and accusing
others of unresolved injustices and overall tend to tell incoherent, hard-to-follow stories
(Holmes, 1993). In effect, attachment styles are essentially narratives we hold about
ourselves and others, and the way we perceive emotions and love.
In recent years, researchers and clinicians have become more interested in the clinical
applications of attachment theory. Although interestingly the clinical applications were
always Bowlby’s central concerns,

It is a little unexpected that, whereas attachment theory was formulated by a

clinician for use in the diagnosis and treatment of emotionally disturbed patients
and their families, its usage hitherto has been mainly to promote research in
developmental psychology. Whilst I welcome the findings of this research as
enormously extending our understanding of personality development and

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 O’SHAUGHNESSY: ATTACHMENT AND EATING DISORDERS

psychopathology, and thus as of the greatest clinical relevance, it has none the less
been disappointing that clinicians have been slow to test the theory’s uses.
(Bowlby, 1988, p. ix)

The lack of published studies has become apparent, and researchers have highlighted
the need for further research (Scott Brown & Wright, 2001, 2003). Generally, research
in this area has confirmed the theoretical proposition that attachment disruption in
infancy is associated with later psychopathology (e.g. Allen, Leadbeater, & Aber, 1994;
Fonagy et al., 1996); and that secondary attachment strategies are linked to attachment
classifications during adolescence (e.g. Brown & Wright, 2001; Scott Brown & Wright,
2003). Empirical studies exploring the connection between attachment and eating
disorders have only recently begun.

Previous reviews
O’Kearney (1995)1 summarized both the theoretical propositions about the connections
between attachment disruption and eating disorders and the empirical work directly
examining these associations. O’Kearney reviewed 10 studies up to 1995 and concluded
that there was evidence of a connection between attachment disruption and the develop-
ment of eating disorders. However, he also highlighted many problems which emerged
including sampling, design, and the measurement of attachment. For example, over half
of the studies reviewed used the Parental Bonding Instrument (PBI; Parker, Tupling, &
Brown, 1979) which is not explicitly linked to formalized attachment constructs. Ward,
Ramsay and Treasure (2000) provide a review of the published empirical literature up
to 1998 and extracted from the following databases: PsychLIT, Medline Express, Embase
and the Cochrane Library. They present their results in three categories: Research using
the PBI, research using nonclinical populations, and research using clinical populations,
with a focus on the latter group. They conclude that insecure attachments are commonly
found in women with eating disorders, however, little is known about specific associ-
ations between attachment style and eating disorder subgroups. The authors also
highlight recurring difficulties in the literature including varying interpretations of terms,
for example, ‘anxious attachment’, and methodological problems including the reliability
of self-report measures.

Aims
The aims of this article are to review the clinical literature which examines the associ-
ation between attachment patterns and eating disorders with a focus on anorexia, and
to comment on the different methods and measures used in attachment research.

Method
Articles for inclusion in this review were identified from two electronic databases:
PsychINFO (1966– 2008) and Scopus (1966–2008). The search terms ‘attachment’, ‘eating
disorders’ and ‘anorexia nervosa’ were used as major descriptors and appropriate papers
were then hand-searched for further articles. Terms such as bulimia and EDNOS were
not employed as the key search terms because we wanted the focus to be on anorexia
as the primary condition and also because we needed to keep the scope of the review
contained and manageable. Studies were considered appropriate if they included the
following criteria: (1) They stated the use of the search terms in the title, key words or

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abstract; (2) were published in the English Language in a peer-reviewed journal, review,
or book chapter; (3) used a clinical research sample. Articles were excluded if: (1) The
study was not published in the English Language or in a peer-review journal, review or
book chapter; (2) used nonclinical populations, for example college students with eating
difficulties; (3) used research instruments which are not specifically related to formal-
ized attachment constructs such as Parental Bonding Instrument (PBI; Parker et al.,
1979); and (4) was solely concerned with researching bulimia or other binge-eating
disorders.

Results
Since the last review (Ward, Ramsay & Treasure, 2000) the number of published studies
using clinical populations has more than doubled, which suggests that this topic is
provoking much interest. The next section will describe the outcomes of empirical
studies and the contribution of attachment research in understanding eating disorders,
particularly anorexia. Findings from clinical applications are then discussed before
moving into a discussion on the different ways attachment patterns and experiences have
been explored by researchers.

The relationship between attachment classification and eating disorder subtype

Over 15 years of research provides empirical support for the theoretical link between
attachment style and eating disorders. Researchers have moved from merely docu-
menting associations between attachment style and eating disorders (Chassler, 1997;
Friedberg & Lyddon, 1996; Kenny & Hart, 1992; Latzer, Hochdorf, Bachar, & Canetti,
2002; Orzolek-Kronner, 2002; Ramaciotti et al., 2001; Salzman,2 1997; Tasca et al., 2006)
to more specific associations which attempt to link attachment style to diagnostic
subgroup (Broberg, Hjamelrs, & Nevonen, 2001; Candelori & Ciocca, 1998; Ringer &
Crittenden, 2007; Tereno, Soares, Martins, Celani, & Sampaio, 2008; Troisi, Massaroni, &
Cussolaro, 2005). More recently, researchers have explored the more complex associ-
ations between attachment, eating disorders and psychiatric symptoms (Zachrisson &
Kulbotten, 2006). Although it is now generally agreed that women with eating disorders
have insecure attachment styles, prevalence is estimated at between 70 (Ramaciotti et
al., 2001) and 100 per cent (Ringer & Crittenden, 2007; Zachrisson & Kulbotten, 2006).
Some authors have found a higher incidence of avoidant attachment style followed
closely by a preoccupied attachment style (Latzer et al., 2002; Ramaciotti et al., 2001) in
eating disorder groups generally. Other authors have reported a higher rate of pre-
occupied attachment style in eating disorder groups (Friedberg & Lyddon, 1996;
Salzman, 1996; Tereno et al., 2008). The evidence linking attachment style to diagnostic
subgroup is also far from conclusive. Some researchers using the Adult Attachment
Interview (AAI; Main & Goldwyn, 1984, 1998) have shown that anorexia is associated
with avoidant/dismissing (Candelori & Ciocca, 1998; Ward et al., 2001) styles while
bulimia is associated with preoccupied/entangled patterns, arguing that anorexia and
bulimia should be treated as two distinct disorders (Candelori & Ciocca, 1998).
However, other research has shown no difference between diagnostic subgroups with
regard to attachment style, suggesting that severity of eating disorders matters more than
type of eating disorder problem (Broberg et al., 2001; Troisi et al., 2005; Zachrisson &
Kulbotten, 2006).
It is clear that outcomes are mixed, making it difficult to come to any solid conclusions.
Results point to methodological problems: Most of these studies use different self-report
measures of attachment and those using the ‘gold standard’ AAI have reported their

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results using small sample sizes. However, there is one study which has tried to address
these flaws. Ringer and Crittenden (2007) offer the most thorough, informative and
complex investigation of attachment style and eating disorders in women to date. The
authors’ overarching aim was to identify particular interpersonal strategies used by
women with varying diagnoses. In this large-scale study, they administered the AAI to
62 women with varying diagnoses and classified transcripts using Crittenden’s Dynamic-
Maturational Model (DMM; Crittenden, 1999, 2000–2004). The DMM describes 10
complexly organised compulsive and obsessive self-protective strategies which keep
people safe from actual or perceived danger. Type A strategies involve the suppression
of negative feelings in an attempt to prevent repercussions from the attachment figure,
and are associated with actual threat or danger, for example compulsive caregiving (A3),
compliance (A4). Type C strategies involve overstated display of feelings which serve to
elicit responses from attachment figures and are associated with an expectation of threat
or danger, for example aggression (C3), punitive (C5). The DMM also includes more
categories with respect to trauma/loss and uses a more complex discourse analysis in
comparison to the more traditional system of analysis developed by Main and Solomon
(1990). The results revealed that all women with eating disorders showed an insecure
attachment style (Type A = 13%, Type C = 50%, Type A/C combined = 37%), and further
analysis indicated that eating disorder type predicted the attachment subpattern. The
authors report that women with anorexia were associated with Types A3–4 (compulsive
caregiving and compliance) and A/C5–6 (idealizing of parents and punitive-and-
seductive); bulimia with Types C3–4, C3–4(5–6) and A/C3–4 (aggressive and feigned
helplessness, sometimes with idealizing of parents) and anorexia/bulimia with Types
C5–6, AC3–4 and A/C5–6 (often punitive-and-seductive, sometimes with idealizing of
parents). Overall, those with anorexia used more A-based patterns and women with
bulimia more C-based patterns, with almost all women using an obsessively coercive type
C strategy. It is noted that there was considerable overlap among the eating disorder
subtypes.
However, though an important study, it would be inappropriate to overgeneralize
conclusions based on one finding and it seems that one cannot determine whether eating
disorder subtype is exclusively associated with a particular anxious attachment pattern.
Although it seems as though anorexia, particularly restricting type, is associated with an
avoidant attachment style this is not clear-cut and clinicians should be wary of making
assumptions and categorizing patients as such. In part the difficulties in finding clear
causal connections here can be seen to be related to starting with DSM diagnostic
classifications which are largely descriptive. However, symptoms such as anorexia may
develop in different family systems for a variety of reasons and follow different causal
pathways. Some researchers have argued that severity of eating disorder matters more
than type of eating disorder problem (Broberg et al., 2001; Troisi et al., 2005) and it might
be more helpful therefore to consider level of distress as the basis of our considerations
rather than symptoms or diagnosis.

The significance of separation difficulties

Clinical studies have reported oversensitivity to early separations in women with eating
disorders (e.g. Sours, 1974) and difficulties with the separation-individuation process
(Bruch, 1978). Some studies have therefore attempted to examine explicitly this aspect
of attachment and results lend empirical support to some of the earliest theories of
eating disorders suggesting that Bruch’s original ideas remain alive and influential today.
Research which examines separation anxiety requires that the participant reflect on
what it is like to be away from an attachment figure thus triggering deeply held beliefs

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 CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 14(4)

and emotions connected to these situations. Armstrong and Roth (1989) found that 96
per cent of their sample reached the criteria for having an anxious attachment with a
startling 85 per cent reaching the criteria for chronic separation depression as measured
by Hansburg’s Separation Anxiety Test (SAT; Hansburg, 1980). Further posthoc analysis
revealed that the clinical sample struggled to differentiate between varying levels of
separations (e.g. brief vs. permanent) suggesting that the developmental task of separ-
ation may not have occurred for this group. Later studies have corroborated these results
reporting that eating disorder samples have higher rates of separation anxiety during
childhood (Troisi et al., 2005, 2006). In Troisi et al.’s (2005) study the most statistically
significant result on the Attachment Style Questionnaire (ASQ; Feeney, Noller, &
Hanrahan, 1994) was on the Need for Approval Scale which suggests that ‘identity is
organized around a strong need for approval from significant others, together with a fear
of rejection from them’ (Troisi et al., 2005, p. 95) which echoes the ‘push–pull’ relation-
ship described by Ward, Ramsay, Turnbull, Benedetti and Treasure (2000) and Ringer
and Crittenden (2007). This ‘push–pull’ interpersonal style might be understood as oscil-
lating between the overwhelming need to be looked after and the determination to keep
intimacy at bay often observed in women with eating disorders. Taken together, this
research indicates that women with eating disorders have extreme difficulties with
separation to the point where they are unable to discriminate cognitively between brief,
everyday leavings and more permanent breaks (Armstrong and Roth, 1989). This is
characteristic of a preoccupied pattern and suggests that everyday separations may
reactivate past traumas, leaving the young woman in a constant state of anxiety.

The significance of an ‘unresolved’ attachment style

Another interesting theme to emerge from this literature is the high incidence of un-
resolved status. Fonagy et al. (1996) found that most of the eating disorder group were
categorized as unresolved (U) with respect to loss or abuse. Ringer and Crittenden
(2007) report that one-third of their sample was rated as unresolved although most of
the unresolved traumas were not based on direct threat to the woman herself. Trauma
included issues such as fighting between parents and experience of parents’ trauma.
Ward et al. (2001) unexpectedly found a high rate of unresolved status in terms of loss
or trauma in both the patient group (50%) and in their mothers (67%). What is inter-
esting about this study is that only just over half the mothers agreed to participate. This
might be interpreted as a covert and powerful statement that they were fearful of or
unable to engage in discussions about their own past and its relationship to their
daughters’ emotional health. The researchers discuss their results in terms of Bruch’s
theories and explain that the mother’s avoidant attachment style would limit her
responsiveness to her daughter’s emotional needs and thus the child never learns to
differentiate between her own needs and feeling states. Tereno et al. (2008) also found
that patients mothers had insecure attachment styles and, more specifically, Ringer and
Crittenden (2007) found that ‘mothers’ AAIs were organized around their own experi-
ences of trauma and loss and the mother’s strong desire that their daughters should not
be affected by this’ (p. 128). They propose that, in effect, mothers strive to protect their
children from the unspeakable threats they had endured in their early lives.

Findings from clinical applications

A small number of studies have explicitly examined attachment style and its impact
on therapy and treatment. Fonagy et al. (1996) investigated the attachment patterns of
82 psychiatric inpatients with various diagnoses including eating disorders (n = 14;
17%). The authors examined changes between admission and discharge according to

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attachment classification and found that individuals categorized as dismissive are more
likely to benefit from psychotherapy (93%). They argue that it may be ‘easier to draw
someone’s attention to past relationships as determinants of current difficulties when
they have previously avoided concerning themselves with such issues than it is to try and
cast a well-established set of perceptions about the past into a different, and probably
far less self-serving mould’ (p. 29). Tasca, Taylor, Bissada, Ritchie, and Balfour (2004)
hypothesized that participants with avoidant attachment patterns would underestimate
positive therapeutic relationships and found partial support for this theory. They found
that anorexia (bulimic) subtype with high avoidant attachment styles predicted non-
completion of treatment, however, this relationship did not emerge for those with
anorexia (restricting) subtype. Strauss et al. (2006) reported that attachment style was
largely insignificant in predicting treatment outcome in a group of 617 service users with
a variety of clinical disorders, including 82 individuals diagnosed with eating disorders.
Again, these contradictory results highlight the problem of attachment classification
system in that there is a danger of assuming that ‘one size fits all’. What is clear is that
it is essential to assess a person’s unique attachment pattern and to understand their
interpersonal strategies and how they developed in the context of their childhood and
life experiences. Strauss et al. further suggest that it may be more important to assess
other features (e.g. unconscious conflicts, ego strength) rather than simply considering
attachment style in order to determine treatment outcome.
Treatment for eating disorders, particularly anorexia, is often dominated by a medical
perspective. This focus on symptoms may reinforce the woman’s ‘substitution of
symptom for relatedness’ (Pearlman, 2005, p. 233) and may in effect strengthen her
defences and resistance to psychotherapy. Given the attachment and separation diffi-
culties of eating-disorder patients it seems appropriate to focus treatment on the
creation of a secure base and the developing of a safe attachment or therapeutic relation-
ship. Bowlby (1979, p. 155) wrote that ‘a therapist should, so far as he can, meet the
patient’s desire for a secure base, whilst recognising that his best efforts will fall short of
what a patient desires and might well benefit from’. Nurturing a therapeutic relationship
can be slow and pain-staking and may be subject to the fear of betrayal and rejection.
The making and breaking of therapeutic relationships and the separations between
sessions must be given exceptional consideration. The job of the therapist is to under-
stand attachment patterns and devote ‘special attention to the patient’s interpersonal
dimension of distress, full respect for his suffering and full awareness of the functional
value of his disturbed behaviour’ (Ardovini, 2002, p. 331). Milkovitch, Pierrehumbert,
Karmaniola, Bader, and Halfon (2005) and Tereno et al. (2008) also emphasize the
importance of understanding and working with the individual attachment cognitions and
representational models of eating disorder groups. Another study suggests that eating
disorders themselves may serve as a ‘false secure base’ and may serve to protect the
young person from the fear of death (Hochdorf, Latzer, Canetti, & Bachar, 2005). The
authors argue therapy should focus on creating an internal sense of security and enrich
patients ‘attraction to life’ thus replacing the ‘illness secure base’ (Hochdorf et al., 2005).
Attachment concepts also extend to the effectiveness in working with families and
several authors have emphasized the importance of working with parents. For example,
Hochdorf et al. (2005) argue that parents must feel a sense of safety and containment
with the therapist in order that they can convey this to their child. This would increase
parents’ capacity for anxiety and reduce the possibility of them trying to control their
child’s feelings or symptoms as a way of containing their own (Pearlman, 2005).
Therapeutic work in this regard remains paramount especially given the possibility of
the unresolved status of parents, particularly mothers. Ringer and Crittenden (2007)

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suggest the usual form of family therapy is insufficient and that therapists must be
prepared to work on an individual, dyadic and family level.

Ways of exploring attachment: Patterns and experience

Two lines of research in attachment theory have evolved: One of which uses self-report
measures and another which uses the Adult Attachment Interview (George et al., 1985),
considered the ‘gold standard’ in attachment assessment. Self-report measures are quick
and easy to administer and give clinicians some ideas about the experience of eating
disorders and the underlying emotional nature of peoples lives. However, these
approaches tend to end up with typologies and classifications which reduce the diversity
and richness of people’s experience to a few categories. These approaches also present
the risk of reactivity and response subjectivity which therefore threatens the validity of
the instruments. Self-report measures may be seen to be unreliable given that when
people talk about their attachments defensive processes are activated but which are not
picked up by questionnaires.
In contrast, the SAT and the AAI are interesting because they explore both the
content and form of people’s accounts. The AAI in particular looks at overt and covert
material, with a focus on the unconscious signals of attachment arousal and anxiety in
the manner of the person’s discourse as they talk during the interview. These approaches
have more potential for understanding people’s lived experiences and for representing
these experiences in a meaningful and emotional way. Research which threads narra-
tives during the discussion gives participants the opportunity to express their voice and
the complexity of their difficulties and allows the reader to be ‘moved’ into under-
standing complex psychological and emotional states. In effect, this brings the research
‘to life’ and allows us to make meaningful connections between research, theory, and
clinical practice. Although there is potential for these approaches to convey people’s
unique experiences, their narratives are often omitted from published papers.
Two notable exceptions are Salzman’s (1997) and Dallos and Denford’s (2008) studies.
Salzman reports on narratives of her eating disorder group with ambivalent attachment
patterns using the adolescent version of the AAI. She threads her participants’ narra-
tives through her discussion and uses them as a window to elaborate the nature of their
experience:
‘Temporary epiphanies’ is the phrase one subject used to describe such moments
in her experience. ‘When the going got rough’, she explained, ‘my mother came
through in ways that really surprised me. I’d be surprised that she could really
understand. Later on, if she didn’t understand something, it would come as a shock
to me, and I could kill her for not being perceptive enough to understand’ (p. 255).
Overall, the participants narratives focused on their perception of their mothers’
emotional inconsistency and the intense but frustrated relationship they had as a result.
These narratives echo other AAI studies which have observed the mother’s emotional
unpredictability and the failure to resolve their own past losses and traumas (Ringer &
Crittenden, 2007; Ward et al., 2001).
Dallos and Denford’s (2008) qualitative study builds on the idea of using narratives
by exploring the experiences of four families each of which included a young woman
diagnosed with anorexia. Interviews with the young person, her parents, and a key sibling
explored family relationships, generational patterns of relating, and the role of food in
relation to comfort and were analysed using a combination of interpretative phenom-
enological analysis (Smith, Jarman, & Osbourn, 1999) and a structured form of discourse
analysis (Crittenden, 2006). This genre of analysis included the analysis of the more

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defended aspects of the accounts, thus exposing a deeper and richer understanding of
the young people’s experiences:

The only thing I ever hear them talking about is me and if I didn’t have this
[anorexia] it’s kind of like . . . would everything fall apart? At least it’s keeping
them talking, and they won’t like argue while I’ve got this because it might make
me worse. So, um . . . it’s kind of like, I’m not in control as such but I’ve got more
control over the situation that way. (Dallos & Denford, 2008, p. 306).

The narrative themes across all four families suggested that the young person with
anorexia was playing an important role in the parents’ attempts to correct their own
negative experiences in childhood and illuminate complex psychological dynamics
between the young people and their families. Most significantly, the study indicated the
almost total absence of a tradition in these families of food as a source of comfort. Far
from it, food was transgenerationally experienced negatively, with painful memories of
family meal times, a joyless relationship with and an absence of its use in family rituals
and celebrations. Furthermore, it appeared that the parents had a ‘corrective’ script, a
wish to have the happy mealtimes that they had never experienced themselves but were
anxious and unsure about how to facilitate this. Hence this study suggested some specific
aspects of food in relation to attachment and significantly how the provision of food is
a vehicle through which attachment processes are built. Salzman (1997) and Dallos and
Denford (2008) are examples of approaches which attempt to utilize the structure of the
AAI and have an interest not only in the classification of accounts but also gives the
style of the narratives which offers a more profound window into the experiences of
people.
Other studies have reported observations in relation to participants’ narratives.
Ringer and Crittenden (2007) report that the most exceptional feature of their inter-
views with women with eating disorders was their reluctance to talk. The authors
describe long periods of silence and difficulty in answering the questions saying
frequently that ‘they didn’t know why and were sorry but they just couldn’t answer the
question, they didn’t know why, they couldn’t remember’ (p. 127). Similarly other
authors have reported on the characteristics of narratives with a particular attachment
style. For example, anorexic women classified as avoidant tend to describe their lives
logically rather than depending on memories, and their narratives less connected with
emotional states (Candelori & Ciocca, 1998). It could be argued that these narratives
lack reflexivity and avoid painful memories. This fits well with empirical studies that
found that patients with eating disorders had high idealization of their parents and low
reflective functioning scores on the AAI (Fonagy et al., 1996; Ringer & Crittenden, 2007;
Ward et al., 2001).

Discussion
The literature reviewed has highlighted important issues to consider when working with
this group. First, separation anxiety appears to be felt intensely by women with eating
disorders and they may have difficulty in discriminating between brief and more
permanent breaks. These intense feeling states seem to fit well with difficulties in
emotional regulation first proposed by John Bowlby. Pearlman (2005) expands this issue
and writes,

he or she may attempt comfort and permanently dissociate himself from intoler-
able levels of anxiety through thumb or pacifier sucking or demands for food.

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These self-regulatory mechanisms may become entrenched and imprinted as the

primary means of comfort and self-care, replacing human attachment and mutual
caring. (p. 230).

The author points out that, as well as literal separations, this damage could also be done
by the ‘emotional absence of a physically present mother’ (p. 230).
The second issue to emerge from the literature review is the high incidence of un-
resolved trauma and loss found in both patients (Fonagy et al., 1996; Ringer &
Crittenden, 2007; Zachrisson & Kulbotten, 2006) and their mothers. However,
researchers have attached different meanings to ‘trauma’ and ‘loss’. For example, Fonagy
et al. (1996) found a high rate of unresolved status with respect to abuse or loss while
Ringer and Crittenden’s (2007) sample similarly showed a high incidence of unresolved
status but this was connected to difficulties in resolving issues such as continued and
distressing ‘fighting between parents’ and a vicarious ‘experience of their parents’
trauma’. However, Ringer and Crittenden’s findings are interesting and reflect the
earliest clinical literature which pointed to the mothers’ own difficulties and the impact
of these on the developing child (Bruch, 1973, 1978). Two studies which have explored
the mother’s AAI’s and have found high rates of unresolved loss or trauma status
(Crittenden & Wilkinson, 2005; Ward et al., 2001) and thus corroborate these findings.
However, it appears that fathers’ have largely been neglected from this area of research
and further research is needed to understand the dyadic nature of attachment theory in
terms of both parents. Furthermore, the question arises as to how research instruments,
in particular self-report measures, might identify and understand unresolved issues?
There is an implicit assumption that people can talk about their experiences but issues
such as trauma and loss might be more difficult to reveal. This must be given consider-
ation in future research. Qualitative research might offer one way of listening to both
what people are saying and what might be more difficult to say or what is unresolved.
As mentioned, researchers have attached different meanings to ‘trauma’ and ‘loss’
which points to a significant methodological problem in the literature – the confusion of
terminology. More specifically, attachment classifications are used interchangeably
(anxious/ambivalent/preoccupied) when in fact different assessment measures define the
terms slightly differently (Ward, Ramsay, & Treasure, 2000). Future research would need
to address these issues. A central question also is whether these attachment findings are
general or specifically explain anorexia. We suggest that they are both general ‘risk’
factors in terms of other forms of psychiatric distress but can also offer some specific
explanations regarding anorexia. However, we cannot make general nomothetic
generalizations that a particular attachment pattern predict anorexia but when we add
qualitative data from the young women’s AAIs about their position in their family
systems, for example as in a position of managing the conflicts between their parents, we
can start to understand the causal links further. Dallos and Denford’s (2008) study
specifically looked at the connections between the provision of food and attachment
relationships. Though it was a small-scale study perhaps it points to larger studies that
could explore the role of the provision of food in building attachment patterns.
Interestingly this study suggested that it was a combination of the parents’ insecure
attachment patterns (a general risk factor) and the absence across the generations of
food as a source of comfort along with the parents’ anxious attempts to remedy this
(specific factor) which perhaps resulted in the young women developing anorexia as
opposed to self-harm, depression or other conditions.
A small number of studies have attempted to associate attachment style with eating
disorder subtype but results have been contradictory and it is premature to draw any

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conclusions. It may be more helpful therefore to consider level of distress as the basis
of our considerations rather than symptoms or diagnosis. For Bowlby (1973, 1980) the
key issue is that early attachment experiences shape ‘internal working models’. These in
effect are meaning-making systems whereby we come to predict the emotional avail-
ability of others and our own value as potential objects of affection. The danger is that
this ‘complex working model’ becomes reduced to a small number of classifications, even
in Crittenden’s model. Research is needed into understanding these subtle, complex and
unique models and may be achieved by qualitative research, in particular narrative
research.
It has been suggested that allowing people to provide narrative accounts of their
experiences can provide good evidence about their everyday lives and the meanings they
attach to their experiences. This approach would also allow the researcher to preserve
the uniqueness of each person’ story, and could help to redress some of the power differ-
entials inherent in the research enterprise.

Notes
1. Please note that O’ Kearney does not provide information pertaining to the review
methodology, that is to say, there is no description of which databases were searched.
2. Although this study did not recruit from a clinical population it emerged that participants
with eating disorders were diagnosed by a physician and so the findings are included in
this article.

References
Allen, J.P., Leadbeater, B.J., & Aber, J.L. (1994). The development of problem behaviour
symptoms in at-risk adolescents. Development and Psychopathology, 6, 323–342.
Ainsworth, M.D.S., Blehar, M.C., Walters, E., & Wally, S. (1978). Patterns of attachment: A
psychological study of the strange situation. Hillsdale, NJ: Erlbaum.
Ardovini, C. (2002). Attachment theory, metacognitive functions and the therapeutic
relationship in eating disorders. Eating and Weight Disorders, 7, 328–331.
Armstrong, D.M., & Roth, J.G. (1989). Attachment and separation difficulties in eating
disorders: A preliminary investigation. International Journal of Eating Disorders, 8(2),
141–155.
Bowlby, J. (1969). Attachment. New York: Basic Books.
Bowlby, J. (1973). Separation, anxiety and anger. New York: Basic Books.
Bowlby, J. (1979). The making and breaking of affectional bonds. London: Tavistock.
Bowlby, J. (1980). Attachment and loss. New York: Basic Books.
Bowlby, J. (1988). A secure base: Clinical applications of attachment theory. Padstow:
Brunner-Routledge.
Broberg, A.G., Hjalmers, I., & Nevonen, L. (2001). Eating disorders, attachment and
interpersonal difficulties: A comparison between 18- to 24-year old patients and normal
controls. European Eating Disorders Review, 9, 381–396.
Brown, L., & Wright, J. (2001). Attachment theory in adolescence and its relevance to
developmental psychopathology. Clinical Psychology and Psychotherapy, 8, 15–32.
Bruch, H. (1973). Eating disorders. New York: Basic Books.
Bruch, H. (1978). The golden cage: The enigma of anorexia nervosa. Cambridge, MA:
Harvard University Press.
Bruch, H. (1982). Anorexia nervosa: Therapy and theory. American Journal of Psychiatry,
139, 1531–1538.

571

Downloaded from ccp.sagepub.com at UCL Library Services on September 24, 2010

 CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 14(4)

Candelori, C., & Ciocca, A. (1998). Attachment and eating disorders. In P. Bria, A. Ciocca, &
S. De Risio (Eds.), Psychotherapeutic issues in eating disorders: Models, methods and
results (pp. 139–153). Rome: Universo.
Chassler, L. (1997). Understanding anorexia nervosa and bulimia nervosa from an
attachment perspective. Clinical Social Work Journal, 25(4), 407–423.
Crittenden, P.M. (1999). Attaccamento in età adulta: Un approccio dinamico-maturativo
all’analisi dell’Adult Attachment Interview. Milano: Cortina.
Crittenden, P.M. (2000–2004). Adult Attachment Interview: Coding manual for the Dynamic-
Maturational Model Method.Unpublished manuscript.
Crittenden, P. (2006). Personal communication.
Crittenden, P.M., & Wilkinson, S.R. (2005, April). Invited Symposium: ED Patient: Innocent
or complicitious victim? An exploration of self-protective strategies in ED. Eating
Disorders Conference, London.
Dallos, R., & Denford, S. (2008). A qualitative exploration of relationship and attachment
themes in families with an eating disorder. Clinical Child Psychology and Psychiatry,
13(2), 305–322.
Dalzell, H. (2000). Whispers: The role of family secrets in eating disorders. Eating Disorders,
8, 43–61.
Fairburn, C.G., & Brownell, K.D. (2002) Eating disorders and obesity. London: Guilford
Press.
Farber, S.K. (2008). Dissociation, traumatic attachments, and self-harm: Eating disorders and
self-mutilation. Clinical Journal of Social Work, 36, 63–72.
Feeney, J.A., Noller, P., Hanrahan, M. (1994). Assessing adult attachment. In M.B. Sperling
& W.H. Berman (Eds.), Attachment in adults: Clinical and developmental perspectives
(pp. 128–152). New York: Guilford Press.
Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoon, G., et al. (1996). The
relation of attachment status, psychiatric classification, and response to psychotherapy.
Journal of Consulting and Clinical Psychology, 64, 357–365.
Friedberg, N.L. & Lyddon, W.J. (1996). Self–other working models and eating disorders.
Journal of Cognitive Psychotherapy: An International Quarterly, 10(3), 193–203.
George, C., Kaplan, N., & Main, M. (1985). Adult Attachment Interview. Unpublished
manuscript.
Hansburg, H.G. (1980). Adolescent separation anxiety: A method for the study of adolescent
separation problems. New York: Robert E. Kreiger.
Hochdorf, Z., Latzer, Y., Canetti, L., & Bachar, E. (2005). Attachment styles and attraction
to death: Diversities among eating disorder patients. The American Journal of Family
Therapy, 33, 237–252.
Holmes, J. (1993). Attachment theory: A biological basis for psychotherapy? British Journal
of Psychiatry, 163, 430–438.
Kenny, M., & Hart, K. (1992). Relationship between parental attachment and eating
disorders in an inpatient and college sample. Journal of Counselling Psychology, 39(4),
521–526.
Klayman-Farber, S. (2002) When the body is target: Self-harm, pain and traumatic
attachments. London: Jason Aronson.
Latzer, Y., Hochdorf, Z., Bachar, E., & Canetti, L. (2002). Attachment style and family
functioning as discriminating factors in eating disorders. Contemporary Family Therapy,
24(4), 581–599.
Main, M., & Goldwyn, R. (1984). Adult attachment scoring and classification system.
Unpublished manuscript.
Main, M., & Goldwyn, R. (1998). Adult attachment scoring and classification system.
Unpublished manuscript.
Main, M., & Solomon, J. (1990). Procedures for identifying infants as

572

Downloaded from ccp.sagepub.com at UCL Library Services on September 24, 2010

 O’SHAUGHNESSY: ATTACHMENT AND EATING DISORDERS

disorganised/disoriented during the Ainsworth Strange Situation. In M. Greenberg,

D. Cicchetti, & E. M. Cummings (Eds.), Attachment in the preschool years (pp. 95–124).
Chicago, IL: University of Chicago Press.
Miljkovitch, R., Pierrehumbert, B., Karmaniola, A., Bader, M., & Halfon, O. (2002).
Assessing attachment cognitions and their associations with depression in youth with
eating disorders or drug misuse disorders. Substance Use & Misuse, 40, 605–623.
Minuchin, S., Rosman, D.L., & Baker, L. (1978). Psychosomatic families: Anorexia Nervosa
in context. Cambridge, MA: Harvard University Press.
O’Kearney, R. (1995). Attachment disruption in anorexia nervosa and bulimia nervosa: A
review of theory and empirical research. International Journal of Eating Disorders, 20(2),
115–127.
Orzolek-Kronner, C. (2002). The effect of attachment theory in the development of eating
disorders: Can symptoms be proximity seeking? Child and Adolescent Social Work
Journal, 19(6), 421–435.
Palazzoli, M. (1978). Self-starvation. New York: Jason Aronson.
Parker, G., Tupling, H., & Brown, L. B. (1979). A parental bonding instrument. British
Journal of Medical Psychology, 52, 1–10.
Pearlman, E. (2005). Terror of desire: The etiology of eating disorders from an attachment
perspective. Psychoanalytic Review, 92(2), 223–235.
Ramacciotti, A., Sorbello, M., Pazzagli, A., Vismara, L., Mancone, A., & Pallanti, S. (2001).
Attachment processes in eating disorders. Eating and Weight Disorders, 6, 166–170.
Ringer, F., & Crittenden, P.M. (2007). Eating disorders and attachment: The effects of
hidden processes on eating disorders. European Eating Disorders Review, 15 (2), 119–130.
Salzman, J. (1996). Primary attachments in female adolescents: Association with depression,
self-esteem and maternal identification. Psychiatry, 59, 20–33.
Salzman, J. (1997). Ambivalent attachment in female adolescents: Association with affective
instability and eating disorders. International Journal of Eating Disorders, 21, 251–259.
Scott Brown, L., & Wright, J. (2003). The relationship between attachment strategies and
psychopathology in adolescence. Psychology and Psychotherapy: Theory, Research and
Practice, 76, 351–367.
Smith, J.A., Jarman, M., & Osbourn, M. (1999). Doing interpretative phenomenological
analysis, In M. Murray & K. Chamberlain (Eds.), Qualitative health psychology: Theories
and methods (pp. 218–240). London: Sage.
Sours, J.A. (1974). The anorexia nervosa syndrome. International Journal of Psychoanalysis,
55, 567–576.
Strauss, B., Kirchmann, H., Eckert, J., Lobo-Drost, A., Marquet, A., Papenhausen, R., et al.
(2006). Attachment characteristics and treatment outcome following inpatient
psychotherapy: Results of a multisite study. Psychotherapy Research, 16(5), 579–594.
Swift, W., & Stern, S. (1982). The psychodynamic diversity of anorexia nervosa. International
Journal of Eating Disorders, 2(1), 17–36.
Tasca, G., Taylor, D., Bissada, H., Ritchie, K., & Balfour, L. (2004). Attachment predicts
treatment completion in an eating disorders partial hospital program among women with
anorexia nervosa. Journal of Personality Assessment, 83(3), 201–212.
Tasca, G., Kowal, J., Balfour, L., Ritchie, K., Virley, B., & Bissada, H. (2006). An attachment
insecurity model of negative affect among women seeking treatment for an eating
disorder. Eating Behaviours, 7, 252–257.
Tereno, S., Soares, I., Martins, C., Celani, M., & Sampaio, D. (2008). Attachment styles,
memories of parental rearing and therapeutic bond: A study with eating disordered
patients, their parents and therapists. European Eating Disorders Review, 16, 49–58.
Troisi, A., Di Lorenzo, G., Alcini, S., Nanni, R., Di Pasquale, C., & Siracusano, A. (2006).
Body dissatisfaction in women with eating disorders: Relationship to early separation
anxiety and insecure attachment. Psychosomatic Medicine, 68, 449–453.

573

Downloaded from ccp.sagepub.com at UCL Library Services on September 24, 2010

 CLINICAL CHILD PSYCHOLOGY AND PSYCHIATRY 14(4)

Troisi, A., Massaroni, P., & Cuzzolaro, M. (2005). Early separation anxiety and adult
attachment style in women with eating disorders. British Journal of Clinical Psychology,
44, 89–97.
Ward, A., Ramsay, R., & Treasure, J. (2000). Attachment research in eating disorders. British
Journal of Medical Psychology, 73, 35–51.
Ward, A., Ramsay, R., Turnbull, S., Benedettini, M., & Treasure, J. (2000). Attachment
patterns in eating disorders: The past in the present. International Journal of Eating
Disorders, 28, 370–376.
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.
West, M.L., & Sheldon-Keller, A.E. (1994). Patterns of relating: An adult attachment
perspective. New York: Guilford Press.
Zachrisson, H., & Kulbotten, G. (2006). Attachment in anorexia: An exploration of
associations with eating disorder psychopathology and psychiatric symptoms. Eating and
Weight Disorders, 11(4), 163–170.

574

Downloaded from ccp.sagepub.com at UCL Library Services on September 24, 2010