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Attachment Representation and Illness

Behavior in Somatoform Disorders

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 ORIGINAL ARTICLES
Attachment Representation and Illness Behavior in
Somatoform Disorders
Elisabeth Waller, Dipl Psych, Carl Eduard Scheidt, MD, PhD, and Armin Hartmann, Dipl Psych, PhD
Abstract: Somatoform disorders are characterized by high health
care utilization and conflictual interactions with health care provid-
ers. The aim of the present study was to explore whether patterns of
insecure attachment are a prominent feature of somatoform disorder.
In addition, the links between insecure attachment and health care
utilization were evaluated. Thirty-seven patients with an Interna-
tional Classification of Diseases, 10th Revision diagnosis of somato-
form disorders and 20 healthy control subjects matched for age, sex,
and education were administered the Adult Attachment Interview.
Psychological symptoms and health care utilization were assessed
using various self-report measures. There was a clearly higher
incidence of insecure attachment in the somatoform group compared
with the nonclinical control subjects. In the somatoform group,
dismissing attachment occurred approximately twice as frequently
as the preoccupied pattern of attachment. The results provide evi-
dence for an association between health care utilization and insecure
attachment. Insecure attachment in somatoform disorder may under-
lie problems in interpersonal functioning and in health care
behavior.
(J Nerv Ment Dis 2004;192: 200 –209)
T he primary diagnostic feature of somatoform disorders is
the existence of multiple and variable physical symptoms
without demonstrable pathophysiological processes. These
patients often present a substantial problem to health care
providers. They are characterized by persistent complaints
about bodily symptoms and the tendency to attribute these
symptoms to a physical disease despite their doctor’s re-
peated reassurance of no organic cause. The result is a
destructive pattern of help seeking behavior that commonly
results in difficult and conflictive treatment relationships.
Department of Psychosomatic and Psychotherapeutic Medicine, University
Hospital of Freiburg, Freiburg, Germany.
Send reprint requests to Dipl. Psych. Elisabeth Waller, Department of
Psychosomatic and Psychotherapeutic Medicine, University Hospital of
Freiburg, Hauptstra␤e 8, D-79104 Freiburg, Germany.
Copyright © 2004 by Lippincott Williams & Wilkins
ISSN: 0022-3018/04/19203-0200
DOI: 10.1097/01.nmd.0000116463.17588.07
200 The Journal of Nervous and Mental Disease • Volume 192, Number 3, March 2004
Recently, Bass and Murphy (1995) have suggested that
the problematic behaviors and attitudes that make up the
somatoform disorders reflect a consistent pathological mode
of relating to one’s self and others. Based on their research,
they have argued for conceptualizing the somatoform disor-
ders as a manifestation of a personality pathology that arises
developmentally. Their developmental view of somatoform
disorders is in agreement with recent findings of a high
incidence of personality disorders (Noyes et al., 2001) and of
childhood adversity in this clinical condition (Egle and
Nickel, 1998). Furthermore, the authors have indicated the
importance of future empirical study of the interpersonal and
developmental aspects of somatoform disorders.
The aim of the present study was to apply the devel-
opmental perspective of attachment theory (Bowlby, 1969,
1973, 1980) to somatoform disorders. Current theory and
research on adult attachment rely on Bowlby’s concept of
attachment representation (1973; Bretherton, 1999). Accord-
ing to attachment theory, children internalize early attach-
ment experiences with their principal caregiver and form
relatively stable internal (mental) working models of attach-
ment. These cognitive-affective schemas influence thoughts
and feelings concerning past and future attachment relation-
ships and thus determine social behavior in later attachment-
related situations.
People with secure attachment have usually experi-
enced a sensitive, protective, and emotionally accessible
attachment figure. They have learned to rely on the caregiv-
er’s responsiveness in times of distress. Based on these
experiences, they seek and anticipate helpful encounters with
relationship partners. By contrast, people with an insecure
attachment history have learned that their needs will not be
met. Thus, they have developed secondary attachment strat-
egies according to this expectation. Current attachment the-
ory postulates two basic insecure attachment strategies in-
volving the efforts to play down (insecure dismissing) or
amplify (insecure preoccupied) the expression of distress and
attachment needs (Kobak et al., 1993). A preoccupied state of
mind is associated with an overamplification of the attach-
ment and wariness system (Cassidy, 1994). Thus, the expres-
sion of attachment is heightened even in low-threat situations
The Journal of Nervous and Mental Disease • Volume 192, Number 3, March 2004
in an effort to keep significant others close or entangled. The
polar opposite of the preoccupied dimension, the dismissing
organization, is associated with deactivation of the attach-
ment system. Dismissing people typically restrict negative or
conflicting feelings. They present themselves as invulnerable
in an effort to minimize attachment needs.
The relevance of attachment research for psychoso-
matic medicine has been highlighted recently in two review
articles (Maunder and Hunter, 2001; Scheidt and Waller,
1999). The authors concluded that issues of central impor-
tance for the understanding of psychosomatic illness such as
affect regulation and physiological reactivity in response to
stress and illness behavior may be better understood within
the developmental framework of attachment research. How-
ever, considering specific psychosomatic conditions such as
somatoform disorders, the empirical evidence on the link
between attachment development and psychopathology is
still scarce. Only one study has directly addressed the issue of
attachment representation in patients with somatoform disor-
ders. Patients with somatoform pain disorder were reported to
have an insecure pattern of attachment significantly more
often than patients with a neurologic pain syndrome (neural-
gia of the trigeminus nerve), and this difference was not
attributable to a difference in pain intensity (Slawsby, 1995).
Links between attachment and illness behavior have been
investigated in patients with physical disease but not in
patients with somatoform disorders. Ciechanowski et al.
(2001a) reported a correlation between dismissing attachment
and poorer treatment adherence in patients with diabetes.
These authors also found a link between symptom reporting
and a preoccupied and fearful style of attachment in adult
female primary care HMO patients (Ciechanowski et al.,
2001b). A preoccupied attachment style in this study was
correlated with higher primary care utilization and costs.
Other research has provided evidence that insecure attach-
ment is related to self-reported levels of pain and disability in
patients with arthritis or related conditions (McWilliams et
al., 2000). However, it is important to note that all studies
mentioned relied exclusively on self-report measures. Com-
pared with interview-based attachment measures, self-report
measures seem to address very different constructs (Crowell
and Treboux, 1995). Empirical work is needed for further
validation using other research methodology.
The aim of the present study was a) to examine the
prevalence of insecure attachment patterns in patients with
somatoform disorders and b) to investigate the correlations
between attachment and illness behavior such as health care
utilization and symptom report. Illness behavior is a central
characteristic of somatoform disorders. A link between at-
tachment and illness behavior may shed light on some of the
developmental aspects of somatoform disorders.
© 2004 Lippincott Williams & Wilkins
Attachment and Somatoform Disorders
PARTICIPANTS AND METHODS
Participants
Fifty-seven subjects participated in the study, 37 pa-
tients with an International Classification of Diseases, 10th
Revision (ICD-10) diagnosis of somatoform disorders and 20
healthy control subjects matched for age, sex, and education.
Thirty-two of the patients with somatoform disorders were
recruited from a special outpatient clinic for somatoform
disorders at the Department of Psychotherapy and Psychoso-
matic Medicine of the University Hospital of Freiburg. Five
patients were recruited from the psychotherapy ward of an
affiliated psychosomatic hospital, the Werner-Schwidder-
Klinik, Bad Krozingen.
Patients had to fulfill the following criteria: a) ICD-10
criteria for somatization disorder, undifferentiated somato-
form disorder, somatoform autonomic dysfunction, or so-
matoform pain disorder, with subjects assigned to the diag-
nostic category of dissociative disorder removed from the
study sample; b) a symptom duration of at least 6 months; c)
exclusion of severe physical or mental illness; d) age between
18 and 65 years; and e) sufficient fluency of language for
psychological testing.
The diagnosis was established through a clinical inter-
view checking for the diagnostic criteria according to the
guidelines suggested by the ICD-10 and additional psycho-
logical testing (Margraf, 1994; Rief et al, 1997). Patients
selected for the study usually had an extensive medical
assessment including a physical examination and electro-
physiological, radiological, or neuroradiological procedures
before the diagnosis of a somatoform disorder was estab-
lished.
A substantial proportion of the patients visiting the
outpatient clinic (as many as 70%) were not suitable for
participation, either because they did not fulfill the diagnostic
criteria for a main diagnosis of somatoform disorders or
because of somatic comorbidity, a lack of language ability, or
a lack of motivation to cooperate in a study that required
extensive psychological testing.
Control subjects were recruited through newspaper ad-
vertisement. They were screened for eligibility by a telephone
interview. Subjects passing the screening interview were
administered the SOMS (Rief et al., 1997). Those who were
included were matched pairwise with the somatoform pa-
tients for age, sex, and education. All participants gave
informed consent before entering into the study. The study
was approved by the local research ethics committee.
Instruments
All measures were administered to somatoform patients
and nonclinical comparison subjects. Only the Mini-Diagnos-
tic Interview for Psychic Disorders (Mini-DIPS; Margraf,
201
Waller et al. The Journal of Nervous and Mental Disease • Volume 192, Number 3, March 2004
1994) and measures assessing health care utilization were
applied exclusively to the patients.
Adult Attachment Interview and Classification
The Adult Attachment Interview (AAI; George et al.,
1985; see also Hesse, 1999) is a semistructured interview
designed to assess a subject’s current state of mind with
respect to attachment experiences. The crucial task for the
subject is to maintain a coherent and collaborative narrative
while answering and reflecting on 18 questions regarding
various aspects of attachment history. The AAI is a well-
researched instrument with good psychometric properties
(Hesse, 1999). Evidence of the reliability and validity of the
AAI and the AAI-Q-Sort rating system in clinical populations
has been obtained in a variety of studies in patients with
serious psychopathological disorders (Dozier, 1999).
Evaluation is based on formal organization of autobio-
graphical discourse, considering linguistic features and co-
herency of discourse (Main and Goldwyn, 1985–1998). The
scoring of the AAI results in three main adult attachment
classifications: autonomous, dismissing, and preoccupied. In-
terviews are classified as autonomous when the speaker is
able to give a clear, objective, and coherent account of
attachment experiences, whether these experiences have been
positive or negative. Interviews are placed in the dismissing
category if the discourse is marked by contradiction and
restricted access to attachment-related experiences. The sub-
ject idealizes or derogates parents, insists on lack of recall,
and lays emphasis on normalcy. Subjects are judged preoc-
cupied if they seem overinvolved in their own attachment
memories, resulting in a confused, excessive, and unobjective
narrative. Anger or passivity characterizes this discourse
style. The interview was audiotaped, then transcribed verba-
tim and made neutral with respect to clinical status. At least
two trained raters who had not conducted the interview rated
the transcripts independently. One of the coders (E. W.) was
taught the AAI scoring and classification system (Main and
Goldwyn, 1985–1998) at an AAI workshop in Austin held by
a qualified trainer (Deborah Jacobwitz, University of Austin).
The other coders were trained in the AAI-Q-Sort method by
rating test cases from a study sample from the University of
Regensburg (Peter Zimmermann) until a sufficient interrater
reliability was achieved. The classification of these cases was
regulated for agreement with the Main and Goldwyn (1985–
1998) rating method.
The Attachment Q-set (Kobak, 1993) was used as a
scoring method. A total of 100 Attachment Q-set items were
placed in nine categories ranging from most characteristic of
the interview to least characteristic. The sorting had to fit to
a forced unimodal distribution (5, 8, 12, 16, 18, 16, 12, 8, 5).
For each interview, the agreement of the two raters had to
meet a criterion of .60. A third rater was used when the
criterion level was not met. This was the case in 15% of the
202
total sample. Analysis of interrater reliability yielded a mean
of .72, ranging from .62 to .86 (Spearman-Brown formula). A
composite Q-Sort was then generated by averaging the place-
ments of both raters for each of the 100 items. Composite
interview Q-Sorts were then correlated with four prototype
Q-Sorts (secure, dismissing, preoccupied, deactivating) gen-
erated by experts on the basis of conceptual criteria. Four
correlation coefficients were obtained, from which categori-
cal attachment groups (according to the three-category sys-
tem of Main and Goldwyn, 1985–1998) were determined
(Kobak et al., 1993); subjects were classified as secure if their
correlation with the secure prototype was positive. The dis-
missing category was assigned if the subject’s Q-Sort corre-
lated negatively with the secure prototype and positively with
the dismissing prototype. Subjects were allocated to the
preoccupied group if their Q-Sort correlated negatively with
the secure prototype and positively with the preoccupied
prototype. Studies comparing the Main and Goldwyn (1985–
1998) system and the Q-Sort system revealed overlap ranging
from 61% to 79%.
To validate the three groups obtained by the algorithm
outlined, a one-way analysis of variance (ANOVA) was
calculated looking at the differences between the three groups
on the four Q-Sort dimensions (secure, dismissing, preoccu-
pied, and deactivating attachment strategy). As can be seen in
Table 1, significant differences emerged between the three
groups in all four Q-Sort dimensions (secure, dismissing,
preoccupied, deactivating). Scheffé post hoc tests indicated a
significant difference between the three groups in at least one
of the four Q-Sort dimensions. Between the secure and the
preoccupied group, no significant difference emerged on the
deactivating dimension. As expected, the two groups with
insecure attachment (the dismissing and the preoccupied
group) did not differ significantly on the secure dimension.
Attachment strategies in this study were unrelated to
age, sex, and level of education, except for females, who had
lower scores on deactivation than men (t ⫽ 2.5, df ⫽ 56, p ⬍
.05).
Psychiatric Diagnosis
To screen for somatoform symptoms, the SOMS (Rief
et al., 1997) was used. The SOMS is a self-reporting instru-
ment that includes 68 items inquiring into physical symptoms
that are common in somatoform disorders. The questionnaire
is a useful screening instrument in determining whether a
specific somatoform disorder is polysymptomatic or mono-
symptomatic. The definite diagnosis of a somatoform disor-
der was established according to ICD-10 criteria based on a
medical and psychiatric assessment, which was performed by
a trained psychiatrist (MD) or clinical psychologist.
In addition, all patients were screened for lifetime and
current ICD-10 (Dilling et al., 1991) diagnoses using the
Mini-DIPS (Margraf, 1994). According to ICD-10, the Mini-
© 2004 Lippincott Williams & Wilkins
The Journal of Nervous and Mental Disease • Volume 192, Number 3, March 2004 Attachment and Somatoform Disorders

TABLE 1. Means and SDs of Attachment Groups on the Four Attachment Dimensions (Total Sample, N ⫽ 55)

Attachment group
Attachment Secure Dismissing Preoccupied
strategies (N ⴝ 21) (N ⴝ 22) (N ⴝ 12) F (2,54) Post hoc (Scheffé)

Secure .30 (.28) ⫺.42 (.21) ⫺.26 (.23) 49.75a Sb ⬎ D,c Pd

Dismissing ⫺.25 (.29) .46 (.18) .04 (.23) 50.66a D ⬎ S, P; P ⬎ S
Preoccupied ⫺.04 (.18) .06 (.17) .49 (.16) 37.94a P ⬎ S, D
Deactivation ⫺.13 (.19) .34 (.13) ⫺.22 (.18) 62.14a D ⬎ S, P
a
p ⬍ .001.
b
S, secure.
c
D, dismissing.
d
P, preoccupied.

DIPS is a reliable and valid interview for the psychiatric
assessment. Checklists were applied for the following diag-
nostic categories: affective and anxiety disorder, somatoform
disorder, eating disorder, obsessive-compulsive disorder,
substance abuse, and psychotic disorder.
Psychological Symptomatology
The SCL-90-R (Derogatis, 1977) is a 90-item multidi-
mensional self-report inventory designed to screen for a
broad range of psychological problems and symptoms of
psychopathology. It is a well-researched instrument with
good psychometric proprieties.
Somatization
The report of physical symptoms (somatization) was
measured using three instruments. a) The Giessener Beschw-
erdebogen (GBB; Brähler and Scheer, 1995) is a self-report-
ing instrument for health complaints. The questionnaire
yields four summary scores: exhaustion, heart problems,
rheumatic pain, and stomach trouble. In the present study,
only the total score of the GBB was used. b) The somatization
scale of the SCL-90-R (Derogatis, 1977) includes 12 items
that refer to functional physical symptoms (e.g., faintness,
chest pains, trembling, low back pains, heart poundings,
nausea). c) The Short Form-12 Health Survey (SF-12; Bull-
inger and Kirchberger, 1998) is a self-reporting questionnaire
including 12 items assessing health status. The instrument
yields two sum scores, one for physical and one for mental
functioning. The two sum scores of the SF-12 were demon-
strated to be equivalent to those of the SF-36. In the present
study, only the physical impairment scale of the SF-12 was
used.
Negative Affectivity
The Hospital Anxiety and Depression Scale (HADS;
Zigmond and Snaith, 1983) was used to measure negative
affectivity. This construct was considered as a covariate of
self-reported physical symptoms. The HADS is a reliable and
valid self-report instrument consisting of two subscales: anx-
iety and depression. Items related to somatic symptoms are
excluded, which makes the questionnaire appropriate to
screen for affective disorder among hospital populations. The
total sum score of the HADS is an indicator of general
emotional distress (Herrmann, 1997).
Health Care Utilization
Assessment of health care utilization was determined
from questionnaire responses. Two types of health care ser-
vices were assessed: general practitioner (GP) visits and
medical inpatient treatment during the year preceding the
current assessment.
Statistical Analyses
For all statistical analyses, SPSS version 11.0 software
was used. Differences between patients and healthy controls in
the distribution of attachment representations were analyzed
using the chi-square test. One-way ANOVAs were performed to
determine whether somatoform disorder subtypes (somatization
disorder, somatoform pain disorder, somatoform autonomic dis-
order) differed on the four attachment dimensions (secure, dis-
missing, preoccupied, deactivation). The association between
attachment strategies and other variables such as illness
behavior and symptom reporting (somatization) was tested by
univariate correlations (Spearman’s rho coefficients, Pearson
coefficients). We repeated these analyses this time controlling
for NA (partial rank correlation, partial correlation). Hierar-
chical multiple regression analyses were applied to explore
whether associations between attachment variables and som-
atization held up when simultaneously controlling for sex,
age, and NA. Sex, age, and NA were entered in the first step,
and the secure, dismissing, and deactivating dimensions of
attachment were tested separately in the second step. Signif-
icance was set at alpha ⫽ .05. All tests performed were
two-tailed.

© 2004 Lippincott Williams & Wilkins 203

Waller et al. The Journal of Nervous and Mental Disease • Volume 192, Number 3, March 2004

RESULTS Of the patients, 60% had a second psychiatric diagno-

sis. In 8.6%, this was a diagnosis of anxiety disorder; in
Sample another 8.6%, depression; and in 17.4%, an adjustment dis-
Two AAIs were not classifiable, reducing the total
order with longer depressive reaction. Of somatoform pa-
study sample to 35 patients and 20 nonclinical control sub-
tients, 11.4% met the criteria for a personality disorder. The
jects. Demographic and clinical characteristics for the final
duration of the most prevalent symptom was 98 months
sample are presented in Tables 2 and 3.
(range, 6 to 240 months).
Demographic Characteristics
The somatoform patient group consisted of 16 men and Attachment
19 women. The mean age was 43.08 years (SD, 10.75). Of
We first compare the distribution of attachment patterns
the group, 74.3% had secondary education, and 25.7% had a
between the somatoform patients and controls by attachment
high school diploma. In the nonclinical control group, the
groups (secure, insecure dismissing, insecure preoccupied
distribution of sexes was equal (10 men and 10 women). The
attachment groups). Then, correlations between attachment
mean age in this group was 42.75 (SD, 10.42). Eight-five
and health care utilization are considered using the four
percent of the comparison group had secondary education,
Q-Sort dimensions of attachment (secure, dismissing, deac-
and 15% had a high school diploma.
tivating, preoccupied dimensions). The interrelations between
Physical and Psychological Symptoms in the Q-Sort dimensions and the attachment groups are dis-
Somatoform Patients and Controls cussed in the Methods section and can be seen in Table 1.
A comparison of symptoms between somatoform pa-
tients and control subjects using independent t-tests yielded
Distribution of Attachment Patterns in
significant differences (Table 3). The somatoform disorders
Somatoform Patients and in Controls
group reported significantly more medically unexplained
In the somatoform patient group, insecure patterns of
symptoms (SOMS-Index) than controls. They scored higher
attachment were clearly more prevalent (Table 3). A total of
on the physical impairment scale of the SF-12 and on the total
17 patients (48.6%) were classified as insecure dismissing,
sum scale (NA) and the depression and anxiety scales of the
nine patients (25.7%) as insecure preoccupied, and nine
HADS. Overall psychopathology (SCL-90-R) was higher in
patients (25.7%) as secure. In contrast, in the nonclinical
patients with somatoform disorders compared with healthy
control group, secure attachment was clearly more prevalent.
controls.
In this group, 12 subjects (60%) were classified as secure, five
Diagnoses (Somatoform Disorders Group) (25%) as insecure dismissing, and three (15%) as insecure
Somatoform pain disorder was the most frequent diag- preoccupied. A comparison of the distribution of insecure
nosis (42.9%). Somatoform autonomic dysfunction ranked versus secure attachment across the two subsamples yielded
second (28.6%), and somatization disorder ranked third significant differences (chi-square ⫽6.34, df ⫽ 1, p ⬍ .05):
(25.7%). The diagnosis of an undifferentiated somatoform somatoform patients were significantly more often classified
disorder was made in only one patient (2.9%). as insecure than subjects of the comparison group.

TABLE 2. Demographic characteristics of patients with somatoform disorders and healthy

controls

Patients (N ⴝ 35) Controls (N ⴝ 20) Analyses

Demographic characteristics N (%) N (%) Chi-square (df ⴝ 1)

Sex (% female) 19 (54.3) 10 (50) .01

Married (% yes) 23 (65.7) 8 (40) 3.42
Employed (% yes) 17 (58.6) 14 (70) 2.37
Education (%)
High school diploma 9 (25.7) 3 (15)
Secondary education 26 (74.3) 17 (85) .86

Mean (SD) Mean (SD) t

Age 43.08 (10.75) 42.75 (10.42) .35

204 © 2004 Lippincott Williams & Wilkins

The Journal of Nervous and Mental Disease • Volume 192, Number 3, March 2004 Attachment and Somatoform Disorders

TABLE 3. Clinical Characteristics and Attachment Classification of Patients with Somatoform Disorders and Healthy Controls

Patients (N ⴝ 35) Controls (N ⴝ 20) Analyses

Clinical characteristics Mean (SD) Mean (SD) t

SOMS Index 14.79 (8.07) 3.8 (5.43) 5.26a

SF-12 Physical functioning 33.94 (9.05) 52.36 (5.67) ⫺9.07a
HADS depression 9.29 (4.27) 3.47 (3.12) 5.22a
HADS anxiety 9.69 (4.08) 4.58 (3.01) 4.79a
HADS total sum score (NA) 18.97 (7.34) 8.05 (5.20) 5.86a
SCL-90-R GSI 82.51 (29.65) 48.58 (10.97) 5.86a

Attachment classification N (%) N (%) Chi-square (df ⴝ 1)

Secure 9 (25.7) 12 (60%) Secure vs.

Insecure dismissing 17 (48.6) 5 (25%) insecure:
Insecure preoccupied 9 (25.7) 3 (15%) 6.34b
a
p ⬍ .001. bp ⬍ .05.

Attachment Strategies by Somatoform Associations Between Attachment and Health

Disorders Subtypes
To determine whether subtypes of somatoform disorders
differ on the four attachment dimensions (secure, dismissing,
preoccupied, deactivating), ANOVAs were performed. From
this analysis, the undifferentiated somatoform disorder group
had to be removed because of its small size (N ⫽ 1). Among the
three remaining diagnostic categories, somatization disorder
(N ⫽ 9), somatoform pain disorder (N ⫽ 15), and somatoform
autonomic disorder (N ⫽ 10), no significant differences were
found on any of the four attachment dimensions.
Health Care Utilization in Patients With
Somatoform Disorders
A total of 16 (45.7%) patients in our sample had more
than 10 GP visits in the preceding year. During the same time,
60% of the patients were admitted for inpatient treatment.
Inpatient treatment lasted 2.9 weeks on average (SD, 3.3;
range, 0 to 13.5). There was no correlation between number
of GP visits and number of hospital admissions. Demo-
graphic variables (gender, age, educational level) were unre-
lated to health care utilization.
Care Utilization
To examine the associations between attachment and
health care utilization, nonparametric correlations between
attachment dimensions and health care utilization were calcu-
lated. Table 4 shows the results. The two insecure attachment
strategies showed a diverse pattern with regard to outpatient and
inpatient care: Insecure dismissing attachment correlated posi-
tively with the number of hospital admissions but not with GP
visits. Insecure preoccupied attachment, in contrast, correlated
positively with the number of GP visits but not with hospital
admissions. Secure attachment correlated negatively with the
number of hospital admissions but not with GP visits. The
correlations remained statistically significant when computing
partial rank correlations, controlling for NA.
Correlations Between Attachment and Physical
Symptom Report (Somatization)
To investigate associations of attachment and self-
reported physical symptoms, correlations were calculated
between the four attachment dimensions and the following
scores: SCL-90-R, scale 1 (somatization), GBB total score,

TABLE 4. Spearman’s rho correlations between attachment strategies and health care
in patients with SD (N ⫽ 35)

Attachment strategies
Secure Dismissing Preoccupied Deactivating NA

GP visits ⫺.23 .23 .44a ⫺.08 .06

Number of hospitalizations ⫺.49b .41a .06 .36 ⫺.17
Spearman rho coefficient.
a
p ⬍ .05, bp ⬍ .01.

© 2004 Lippincott Williams & Wilkins 205

Waller et al. The Journal of Nervous and Mental Disease • Volume 192, Number 3, March 2004
GBB somatic attribution score, and SF-12 physical score.
Negative affectivity was controlled for by computing partial
correlations. Table 5 shows the results. Somatization (scale 1
of the SCL-90-R) correlated negatively with the secure di-
mension of attachment and positively with the dismissing and
the deactivating dimension of attachment. Somatic attribution
of symptoms was positively related to the dismissing and the
deactivating dimension of attachment. No significant corre-
lations emerged between attachment variables and the GBB
total score or the SF-12 score for physical complaints.
Because most authors report associations of age and
gender with the frequency of physical symptoms (somatiza-
tion), we also explored whether the observed associations
held up when controlling simultaneously for age, sex, and
NA. Hierarchical multiple regression was used with SCL-
90-R somatization score as the criterion variable. The secure
(beta ⫽ –.44, p ⬍ .05) and the dismissing (beta ⫽ .39, p ⬍
.05) dimensions of attachment were able to account for
additional variance in somatization (16% and 13%, respec-
tively) after controlling for age, sex, and NA.
DISCUSSION
The results of the study can be summarized as follows:
a) In somatoform disorders, insecure patterns of attachment,
as assessed by the AAI, are significantly more frequent than
in a nonclinical control group matched for age and sex. b) Of
the two insecure patterns, insecure dismissing attachment
occurs approximately twice as frequently in somatoform
disorders as the insecure preoccupied type. c) Insecure at-
tachment was associated with health care utilization. d) The
relationship between symptom reporting and attachment sta-
tus is less clear. Although the correlations of the somatization
scale of the SCL-90-R and attachment dimensions are in
agreement with theoretical considerations, the lack of such
correlations with all other scales measuring somatic symptom
report (GBB) and disability levels (SF-12) was unexpected.
TABLE 5. Zero order and partial correlations (controlling for NA) between attachment
strategies and bodily complaints, somatic attribution, and physical functioning in patients with
SD (N ⫽ 35)
Secure
a a
r r
SCL-90-R somatization ⫺.30 ⫺.48c
GBB total score .06 ⫺.17
GBB somatic attribution ⫺.20 ⫺.26
SF-12 physical functioning .03 .08
a
Pearson correlation, controlling for NA.
b
p ⬍ .05.
c
p ⬍ .01.
206
One purpose of the present study was to examine
attachment representation in patients with somatoform disor-
ders. The results confirm previously reported findings that the
incidence of insecure patterns of attachment in clinical pop-
ulations is more than three times as frequent as in nonclinical
samples (van IJzendoorn and Bakermans-Kranenburg, 1996).
Furthermore, the findings are in agreement with other studies
investigating attachment in somatoform disorders—for exam-
ple, in somatoform pain disorder (Slawsby, 1995). The find-
ing of a high proportion of insecure dismissing attachment in
somatoform disorders invites the question whether the devel-
opmental processes that underlie somatization are linked to
specific subtypes of insecure attachment. Although no causal
attributions are possible from the cross-sectional data of the
present study, the finding that 50% of somatoform patients
were classified as dismissing suggests a more intrinsic link
between somatoform disorders and insecure dismissing at-
tachment. It may be hypothesized that insecure dismissing
attachment is linked to a type of psychopathology that in-
volves the diverting of attention from internal feelings of
distress and also a repression of attachment-related affects,
memories, and cognitions. The distribution of attachment in
somatoform disorders is similar to that of eating disorder and
antisocial personality disorder (Dozier et al., 1999). For these
conditions, a similar model of a shifting away of attention
from attachment-related issues might apply. However, it
should be pointed out that somatoform disorders is a diag-
nostic category encompassing different types of patients
whose underlying psychopathology is likely to be heteroge-
neous. (Dozier et al., 1999) pointed to the importance of the
externalization-internalization dimension when considering
the relationships between attachment status and clinical di-
agnosis. This leads us to speculate that the extent to which
somatoform disorders are associated with externalizing
symptomatology (i.e., repression of affect and diminished
affect-awareness) may be more relevant to attachment orga-
Attachment strategies
Dismissing Preoccupied Deactivating
a
r r r r r ra
.32 .44b .10 .13 .20 .32
.03 .21 ⫺.02 .02 ⫺.02 .14
.35b .40b ⫺.14 ⫺.14 .32 .37b
⫺.10 ⫺.14 ⫺.08 ⫺.09 .03 .00
© 2004 Lippincott Williams & Wilkins
The Journal of Nervous and Mental Disease • Volume 192, Number 3, March 2004
nization than the diagnostic label of somatoform disorders.
The results of two previous studies (Scheidt et al., 1999;
Troisi et al., 2001) indicating a link between dismissing
attachment strategies and alexithymia may be interpreted as
supporting this possibility.
It is also important to emphasize that our sample
included diagnostically different subtypes of somatoform
disorders. Furthermore, a comparatively high proportion of
patients was comorbid for axis I and axis II disorders.
Analysis showed that different somatoform disorders sub-
types (somatization disorder, somatoform pain disorder, so-
matoform autonomic disorder) did not differ significantly on
any of the attachment dimensions. The effect of comorbidity
on attachment classification could not be systematically as-
sessed because the numbers of participants in comorbid
groups were too small for statistical analysis. Thus, we cannot
rule out the possibility that comorbid diagnosis may have
systematically influenced the observed distribution of attach-
ment classification. Further studies should include a more
specific group of somatoform disorders to characterize better
the relationship of somatoform disorders with attachment
organization.
A second purpose was to determine whether attachment
representation is related to health care use and symptom
reporting. The results of the present study suggest a signifi-
cant association between attachment representation and
health care utilization. Preoccupied attachment was related to
increased GP contacts and to psychotherapy use, whereas
dismissing attachment was related to more hospital admis-
sions. In the light of attachment theory, it may be hypothe-
sized that in dismissing attachment, the help-seeking behav-
ior is directed to an institution rather than to an individual
person. In contrast, in insecure preoccupied attachment, help-
seeking behavior is directed to a person rather than to an
institution, resulting in a higher number of GP visits.
The findings are somewhat less clear regarding the
association between attachment strategies and somatic symp-
tom report, attribution of symptoms, and symptom-related
disability. Dismissing attachment was associated with higher
levels of self-reported somatic symptoms on the SCL-90-R
somatization subscale, but not on the GBB. Dismissing at-
tachment was also significantly related to attribution of bodily
symptoms to a physical disease. No significant correlations
emerged between attachment strategies and physical impair-
ment. These findings are in contrast with those of a previous
study of a group of adult female primary care HMO patients
in which a preoccupied and fearful (but not dismissing) style
of attachment was linked to higher reporting of bodily symp-
toms (Ciechanowski et al., 2001b). The failure to find similar
associations between type of insecure attachment and symp-
tom report could be a result of the fact that the studies used
different attachment measures. Whereas the former authors
assessed attachment through self-reports, the present study
© 2004 Lippincott Williams & Wilkins
Attachment and Somatoform Disorders
made use of narratives and a language-based classification
system to assess the speaker’s overall state of mind with
respect to attachment. As mentioned, the AAI and self-report
attachment measures address different constructs and are not
related to each other (Crowell et al., 1999). The finding of no
relationship between attachment and symptom-related dis-
ability is in agreement with McWilliams et al. (2000), who
found that in patients with arthritis, attachment accounted for
only a small amount of the variance in self-ratings on pain-
related disability. One explanation for the lack of associations
between attachment strategies and physical impairment in our
study is that factors other than attachment (i.e., specific
condition, chronicity or severity of illness, comorbidity)
might have influenced self-ratings on physical impairment.
More research is needed to clarify this issue.
Insecure attachment strategies have implications for
interpersonal behavior and thus may explain the somatoform
patient’s problematic interactive behavior with health profes-
sionals. Subjects with dismissing attachment present them-
selves as self-reliant, deny their own needs of comfort and
attachment, and are likely to reject significant others. Their
interpersonal distance and rejecting of help pose specific
challenges to the treatment relationship. As was shown in our
study, dismissing attachment is associated with high levels of
self-reported physical symptoms, which again are related to
externalizing forms of psychopathology. Furthermore, it was
shown that somatoform patients with dismissing attachment
seek help within an impersonal context rather than turning to
a person for help. Other research has demonstrated that
dismissing attachment is associated with lack of treatment
adherence (Ciechanowski et al., 2001a), lack of response to
treatment, less self-disclosure, and greater rejection of help
from therapists (Dozier, 1990). The dismissing person’s prob-
lematic behavior in treatment relationships is likely to evoke
feelings of anger in health professionals and often to result in
driving health professionals away. By contrast, patients with
preoccupied attachment pose different challenges to the treat-
ment process. People who are preoccupied tend to present
themselves as vulnerable, distressed, and extremely needy in
an effort to keep others involved. In treatment relationships,
preoccupied attached patients persistently attempt to elicit
care from physicians while expecting that their need will not
be met. As was shown in our study, preoccupied attachment
was associated with high numbers of GP visits relative to the
other attachment groups. Recent data have demonstrated that
preoccupied people had highest primary care costs and utili-
zation (Ciechanowski et al., 2001b) and reported most psy-
chological symptoms (Dozier and Lee, 1995; Pianta et al.,
1996). This type of care-seeking behavior may initially evoke
intensive caregiver behavior and entanglement, but when
exacerbating, inevitably results in provoking negative and
rejecting responses from health professionals. Confronted
with insecurely attached patients, the clinicians’ task is to
207
Waller et al. The Journal of Nervous and Mental Disease • Volume 192, Number 3, March 2004
understand the function of these insecure attachment strate-
gies as they help to defend the patient from intolerable
feelings. Thus, understanding the function behind insecure
attachment behavior and their own reaction to them, clini-
cians may be less vulnerable to display intense countertrans-
ference reactions. This may help clinicians respond to these
patients in a way not consistent with their patients’ lifelong
expectations and experiences in relational contexts.
A number of limitations must be considered. A major
weakness of the study is that we did not include a patient
comparison group with medically ill patients. Thus, our
findings might have been confounded by physical suffering.
The study included a selected population such as patients
referred to a psychosomatic clinic. The results may have no
relevance for patients with somatoform disorders drawn from
other sources. As already mentioned, our sample was com-
paratively heterogeneous for diagnostic issues. Further stud-
ies should include a more homogeneous sample. Because of
the cross-sectional and retrospective design of the study, it
remains unclear what these findings mean in terms of the
causal connection between attachment state of mind and
somatoform disorders. Longitudinal studies are needed to
shed light on this issue. The use of a self-report questionnaire
for assessing health care utilization may lead to reporting
biases. In subsequent research, additional information from
other sources such as physicians’ medical and hospital
records should be obtained for confirmation. In addition,
influences on utilization other than attachment representation
must be considered.
Notwithstanding its limitations, the study is rare in
exploring attachment states of mind in patients with somato-
form disorders as measured by the AAI. The discourse
analysis of AAI narratives allows the assessment of conscious
and unconscious forms of defense and patterns of affect
regulation underlying a person’s attachment organization.
Applying an attachment model to somatoform disorders and
being aware of the regulative function of the different attach-
ment strategies may enhance our understanding and improve
the management and treatment of patients with somatoform
disorders (Hunter and Maunder, 2001). For these reasons, the
clinical implications of attachment representation in patients
with somatoform disorders clearly merit further study.
ACKNOWLEDGMENTS
This study was supported in part by a grant from the
German Research Society (Sche 576/2–1). We thank Prof.
Dr. Rosin (Werner-Schwidder-Klinik, Bad Krozingen) for his
help with the recruitment of patients. Our thanks are extended
to Prof. Dr. K. E. Grossmann, Dr. K. Grossmann, Prof. Dr. P.
Zimmermann, and Dr. F. Becker-Stoll for their assistance in
coding the AAI.
208
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