INVITED PAPER

Attachment and Eating Disorders: A Review of Current

Research
ABSTRACT
Giorgio A. Tasca, PhD* Objective: Attachment insecurity may
Louise Balfour, PhD confer risk for developing an eating disor-
der. We describe domains of attachment
functioning that are relevant to eating
disorders including: affect regulation,
interpersonal style, coherence of mind,
and reflective functioning. Research since
2000 on attachment and eating disorders
related to these domains is reviewed.
Method: We searched MedLine/Pubmed
and PsycINFO from January 2000 to Feb-
ruary 2014 and kept articles that: were
empirical, included adults with a diag-
nosed eating disorder, and used a stand-
ard attachment measure. We retained 50
relevant studies.
mediated by perfectionism and affect
regulation strategies. Type of attachment
insecurity had specific negative impacts
on psychotherapy processes and out-
comes, such that higher attachment
avoidance may lead to dropping out and
higher attachment anxiety may lead to
poorer treatment outcomes.
Discussion: Research to date suggests a
possible relationship between attach-
ment insecurity and risk for an eating dis-
order. More research is needed that uses
attachment interviews, and longitudinal
and case control designs. Clinicians can
assess attachment insecurity to help
inform therapeutic stances and interven-
tions. V
C 2014 Wiley Periodicals, Inc.

Results: Compared to controls, those Keywords: attachment; eating disor-

with eating disorders had higher levels of
ders; anorexia nervosa; bulimia nerv-
attachment insecurity and disorganized
osa; binge eating disorder
mental states. Lower reflective function-
ing was specifically associated with ano-
(Int J Eat Disord 2014; 47:710–717)
rexia nervosa. Attachment anxiety was
associated with eating disorder symptom
severity, and this relationship may be

Introduction and these develop into internal working models of

Over the past 40 years attachment theory1 has
emerged as one of the most important frameworks
for understanding relationship functioning and
affect regulation.2 In particular, attachment theory
provides a developmental and contextual perspec-
tive on adult functioning. Although originally a
theory of child development and adaptation,1,3 the
model has been applied to adult functioning4 and
adult mental health.5 According to the theory,
attachment behaviors (e.g., crying, following, gaz-
ing, grasping) in human infants are necessary to
ensure proximity to a caregiver. Repeated interac-
tions with a caregiver in infancy and childhood
become encoded in the implicit memory system,
Accepted 6 May 2014
Additional Supporting Information may be found in the online
version of this article.
*Correspondence to: Giorgio A. Tasca, PhD; 501 Smyth Road, Box
44, Ottawa, ON, Canada, K1G0H9. E-mail: gtasca@toh.on.ca
The Ottawa Hospital, University of Ottawa, Ottawa, Ontario,
Canada
Published online 23 May 2014 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/eat.22302
C 2014 Wiley Periodicals, Inc.
V observed especially in low risk samples.8
attachment.6 Internal working models become the
bases for consistent ways in which children and
adults interact with the world, experience them-
selves and others, and regulate affect. These func-
tions, especially affect regulation have implications
for eating disorder psychopathology.
Categories of attachment were originally identi-
fied by Ainsworth3 who observed separation and
reunion events between infants and mothers in
naturalistic and laboratory settings. Main4
extended this work to assessing parallel adult states
of mind through the Adult Attachment Interview
(AAI). Both Ainsworth and Main identified securely
and insecurely attached individuals, with attach-
ment insecurity being further divided into dismiss-
ing (i.e., avoidant) and preoccupied (i.e., anxious)
states in adults. Another category of disorganized
attachment related to loss or trauma was later
identified by Main.7 Secure and insecure categori-
zation is remarkably stable as demonstrated by
longitudinal studies from infancy to adulthood,
though changes in attachments over time were

710 International Journal of Eating Disorders 47:7 710–717 2014


Four domains of attachment functioning are rel-
evant to eating disorders: (1) affect regulation, (2)
interpersonal style, (3) coherence of mind, and (4)
reflective functioning. In this review, we will
describe each of the attachment categories (secure,
avoidant, anxious) with particular emphasis on
these four domains of functioning. Then we will
review some of the research since 2000 on adult
attachment and eating disorders that touch upon
these four domains, and conclude with some rec-
ommendations for research and practice.
Adult Attachment
Individuals with greater attachment security are
characterized by the ability to adaptively regulate
affect so that they can maintain a measured
approach and response to interpersonal stressors
and/or the absence of attachment figures.9 Inter-
personally, these individuals are able to accept inti-
macy, and express love and support to others
without feeling overwhelmed, anxious, or dismis-
sive.10 Coherence of mind in the securely attached
is characterized by discourse related to attachment
figures that: is consistent and relevant, provides an
adequate amount of information, and is collabora-
tive given the conversational context. Coherent dis-
course indicates an ability to maintain a mindful
and balanced state of mind when discussing attach-
ment relationships.4 Reflective functioning (i.e.,
mentalizing) in securely attached individuals is
characterized by: recognizing that one’s own mental
state and mental states of others are separate, mak-
ing an explicit effort to identify that mental states
underlie behavior, and appreciating that one‘s
understanding of others‘ mental states may remain
incomplete.11 Reflective functioning is key for abil-
ities like empathy.
Individuals with greater attachment avoidance
are characterized by a dismissing view of the
importance of relationships, especially attachment
relationships.10 These individuals minimize their
emotional experiences so that emotions may be
cut-off from experience, and they may have diffi-
culty expressing their feelings.9 Coherence of mind
tends to be low especially because those with
greater attachment avoidance have a difficult time
generating relevant attachment memories in their
discourse. Further, the amount of information they
provide about attachment relationships is often
sparse.4 In addition, when they do consider close
relationships, they may unrealistically idealize or
be derogatory regarding attachment figures thus
limiting their reflective functioning, i.e., their
International Journal of Eating Disorders 47:7 710–717 2014
ATTACHMENT AND EATING DISORDERS
ability to appreciate others’ internal experiences.11
On the other hand, those with greater attachment
anxiety tend to be highly preoccupied with attach-
ment relationships especially regarding potential
loss or abandonment.10 These individuals likely
hyper-activate their affective system so that they
often re-access emotional experiences especially
related to loss or hurt.9 As a result of their hyper-
activated emotions, their coherence of mind suffers
because current anger and/or self loathing inter-
feres with their narrative discourse about attach-
ment relationships.4 Reflective functioning also
tends to be impaired since these individuals may
struggle with understanding the separateness of
mental states, and their intense emotions may
make it difficult to take a reflective perspective on
their own or others internal experiences.11
Authors of a meta-analysis that included over
10,000 AAIs12 reported that in non-clinical samples
58% were classified as secure, 23% as dismissing
(i.e., avoidant), 19% as preoccupied (i.e., anxious),
and 18% received a superimposed classification of
disorganized. In clinical samples, 27% were classi-
fied as secure, 37% as preoccupied, and 37% as dis-
missing; 43% were additionally classified as
disorganized. Hence, insecure and disorganized
states were over-represented in clinical samples,
including in those with post traumatic stress disor-
der, borderline personality disorder, and depressive
disorders. Research suggests a clear association
between infant disorganized attachment and disso-
ciative symptoms in early adulthood, and between
infant resistant attachment and anxiety disorders in
adolescence.5 Longitudinal studies point to an
increased probability of adult psychopathology
among those with insecure versus secure attach-
ment in childhood.13
One of the controversies and difficulties with
regard to attachment research is related to the
methods by which attachment is measured. Attach-
ment research has advanced along two relatively
independent lines. First, developmental researchers
have relied on observational ratings of attachment
in children or interviews with adults such as the
AAI.4 The AAI measures current mental states with
regard to attachment, and is not necessarily an
autobiographical measure of what actually occurred
in childhood. That is, the main distinction between
secure and insecure adult mental states on the AAI
is based on the patterns of speech in response to 20
questions mainly about experiences with primary
caregivers. This method typically categorizes indi-
viduals as secure or insecure (i.e., with insecure fur-
ther divided into dismissing or preoccupied), with a
possible additional categorization of disorganized
711
TASCA AND BALFOUR
mental states with regard to trauma or loss. A
dimensional scale of reflective functioning may also
be rated using AAI transcripts.11 Second, social psy-
chological researchers have developed a variety of
self report measures of adult attachment that often
focus on current relationships including romantic
relationships. Self report measures tend to result in
dimensional scales, such as attachment avoidance
or attachment anxiety.14A high score on one scale
but not the other indicates greater attachment
avoidance or anxiety, respectively. Low scores on
both scales indicate attachment security, and high
scores on both scales indicate fearful attachment.15
Nevertheless, the scales are commonly treated as
dimensional. These two methods of measuring
attachment (i.e., interview versus self report) tend to
be poorly correlated.16 Likely, these two approaches
assess different and perhaps complementary
aspects of attachment. That is, the AAI measures
unconscious states of mind related to attachment in
adults, whereas self reports likely tap into con-
sciously available information about one’s interper-
sonal relationships and affect regulation. The AAI is
time consuming and challenging to learn and
achieve reliability, and so the number of studies
using the AAI in eating disorder samples tends to be
few with small sample sizes. Self reports are much
easier to administer. Hence there has been a prolif-
eration of attachment research using self reports rel-
ative to studies using the AAI.
As indicated, one purpose of this paper is to pro-
vide a review of the current state of attachment
research in eating disorders. Reviews that have
been published in recent years have focused
almost exclusively on AAI research.17–19 The cur-
rent review will include findings from the AAI and
self-report measures, but will be limited to adult
clinical samples with eating disorders, and since
2000. Rather than provide a comprehensive review
of every study published during that period, we will
focus on five themes related to eating disorders: (1)
the prevalence of attachment insecurity and the
level of reflective functioning; (2) the association
between attachment insecurity and eating disorder
diagnosis or symptom severity; (3) mechanisms by
which attachment may affect eating disorders;(4)
associations with trauma and disorganized mental
states; and (5) the impact on treatment processes
and outcomes.
Search Strategy and Results
We searched the databases MedLine/Pubmed and
PsychINFO using a combination of the key terms
712
‘Attachment’ and ‘Eating Disorder’ or ‘Anorexia Nerv-
osa’ or ‘Bulimia’ or ‘Binge Eating Disorder’. Only
results published from January 2000 to February
2014 were examined in detail, yielding an initial 185
papers. These works were then screened for English
language. Further, to be included, the studies had to:
be empirical research with greater than six partici-
pants (i.e., excluding case studies and theoretical
papers); include adults (>17 years) with a diagnosed
eating disorder in the sample; and use a standard
and valid self report measure of attachment or stand-
ard coding of an attachment interview.
Using these criteria, 46 studies were classified as
meeting criteria for review. Recent reviews of AAI
research18,19 were used to find four additional rele-
vant studies through their reference sections. The
current review is organized along the themes indi-
cated above, and focused on studies that address
the following domains relevant to eating disorders:
affect regulation, interpersonal style, coherence of
mind, and reflective functioning. Hence, our
review included 32 of the 50 studies. A complete
list of the 50 studies is available as online support-
ing information.
Attachment and Eating Disorders
Research
Attachment Insecurity and Reflective
Functioning
A recent meta analysis of attachment, social com-
munication, and social processes in eating disor-
ders20 reported that compared to non-clinical
controls, those with eating disorders had greater
attachment insecurity measured by self report, and
the effect size was large (d 5 1.31). This was the sec-
ond largest effect size, after negative self evaluation
(d 5 2.27), of all of the 11 social process variables
that were reviewed. Similar findings regarding AAI
research were reported by Kuipers and Bekker.17
The prevalence of attachment insecurity in eating
disorder samples ranged from 70%21,22 to 100%.23
Several studies reported higher incidence of avoi-
dant attachment style compared to anxious attach-
ment in samples including anorexia nervosa (AN),
bulimia nervosa (BN), and binge eating disorder
(BED).21,24,25 However not many studies reported
this comparison and so we make no conclusions at
this stage of the research regarding relative preva-
lence of each attachment insecurity category in the
population of those with an eating disorder.
An emerging line of research looks at the role of
mentalizing or reflective functioning in eating dis-
orders. Bateman and Fonagy26 argued that
International Journal of Eating Disorders 47:7 710–717 2014

problems in early attachments and/or later trauma
could disrupt the ability to mentalize, which in turn
may impair affect regulation. Concurrently, binging
and purging or restrictive eating behaviors may be
related to under- or over-controlled affect regula-
tion, respectively.27,28 In a review of three empirical
studies, Kuipers and Bekker17 found that reflective
functioning as assessed through the AAI was signifi-
cantly lower in eating disorder samples largely
made up of those with AN. A recent study published
after that review reported similar levels of reflective
functioning in patients with BN and controls, how-
ever, the distribution of reflective functioning was
bimodal in the BN sample.29 In other words, some
patients with BN had higher reflective functioning
than non-clinical controls but many had lower
reflective functioning than controls, suggesting dis-
tinct subgroups within BN with regard to mentaliz-
ing. In the only study to compare eating disorder
patients to psychiatric patients and non-clinical
controls, Fonagy et al.30 found that inpatients with
eating disorders (therefore likely with AN) had sig-
nificantly lower reflective functioning scores com-
pared to both psychiatric and non-clinical
comparison groups. This study and others31,32 sug-
gest that lower abilities to mentalize may be a spe-
cific feature of eating disorder diagnoses, especially
AN. The cumulative research to date on reflective
functioning and AN is consistent with research on
theory of mind that found that unconscious decod-
ing of others’ emotions without cognitive deduction
was impaired in patients with AN.33
Attachment Insecurity and Eating Disorder
Diagnosis or Severity
Researchers have looked at whether there is a
relationship between eating disorder diagnosis and
attachment category. Based on the literature on per-
sonality and eating disorders34 one could speculate,
for example that those who binge and purge (i.e.,
who have BN) may show greater attachment anxiety
associated with affect dysregulation, whereas those
who engage in dietary restriction (i.e., who have AN)
may have greater attachment avoidance character-
ized by down-playing of affect. Some studies show
significant specific, though inconsistent, differences
in attachment categories or scales among eating dis-
order diagnostic groups,23,24,35,36 but other studies
did not find differences.17,37–39 The inconsistent
findings are not affected by the method by which
attachment was assessed (AAI or self report). At this
stage, we conclude that type of attachment insecur-
ity is not necessarily related to a specific eating dis-
order diagnosis, although attachment insecurity
may be related to severity of eating disorder symp-
toms across diagnostic groups.
International Journal of Eating Disorders 47:7 710–717 2014
ATTACHMENT AND EATING DISORDERS
The possible transdiagnostic importance of
attachment insecurity in part is indicated by
research that examines the relationship between
attachment insecurity and eating disorder symp-
tom severity. In particular, need for approval, an
aspect of attachment anxiety is positively associ-
ated with body dissatisfaction and eating disorder
psychopathology independent of personality
dimensions, demographics, eating disorder diag-
nosis, and depression.35,40–42 Preoccupation with
relationships and fear of abandonment, especially
when expressed as needing others’ approval, may
be a particularly problematic attachment-related
insecurity that may put individuals at risk for
greater eating disorder symptom severity.
Possible Mechanisms
As indicated, attachment insecurity, and perhaps
attachment anxiety in particular, may confer spe-
cific risk for greater eating disorder symptom sever-
ity such as body dissatisfaction.35,40–42 However,
only few studies to date have assessed the possible
mechanisms by which attachment insecurity may
affect eating disorder psychopathology. In a recent
large clinical study using self reports in a mixed
diagnostic sample, Dakanalis et al.37 found that mal-
adaptive perfectionism mediated the relationship
between insecure attachment patterns and eating
disorder symptoms. The authors argued that attach-
ment anxiety or avoidance could be a risk factor to
sensitize one to the negative effects of maladaptive
perfectionism. In another large mixed diagnostic
sample, Tasca et al.43 found that affect regulation
characterized by hyper-activation of emotions
mediated the relationship between attachment anx-
iety and eating disorder symptoms. However,
attachment avoidance had a direct relationship to
eating disorder symptoms not mediated by cutting
off of emotions. Similarly, researchers reported neg-
ative affect and alexithymia were mediators of the
relationship between insecure attachment and
restrained eating or body dissatisfaction, respec-
tively.44,45 These studies, although large and trans-
diagnostic, were cross sectional in nature thus
limiting conclusions about causal relationships.
Nevertheless, the research to date suggests malad-
aptive perfectionism and problematic affect regula-
tion as potential mechanisms to explain how
attachment insecurity might put someone at risk for
or might maintain an eating disorder.37,43
Trauma, Loss, and Disorganized Mental States
Childhood trauma, abuse, and loss occur at a high
rate among those with eating disorders.46 In a cross
713
TASCA AND BALFOUR
sectional study using self reports, researchers47 found
that retrospective reporting of childhood trauma was
directly associated with core eating disorder psycho-
pathology. In addition, attachment avoidance and
attachment anxiety each independently and partly
explained this direct relationship. The authors argued
that childhood adversity might lead to attachment
insecurity, which in turn may maintain or make
some vulnerable to eating disorder symptoms. As
well, some researchers reported that the interaction
between childhood trauma and the short (S) allele of
the serotonin transporter promoter polymorphism
(5HTTLPR) accounted for greater attachment anxiety
in women with BN.48
Attachment theory indicates that childhood
adversity could have disorganizing effects on adult
mental states, and disorganized mental states are
associated with significant psychopathology
among adults.12 Several studies using the AAI
reported high levels of disorganized mental states
in those with eating disorders,18,23 including
among those with BED24 and AN.32,49 In an inter-
esting study, Ward et al.32 found that not only were
patients with AN reporting unresolved trauma and
loss, but disorganized mental states were highly
prevalent among their mothers. This finding, which
needs to be replicated, suggests possible transge-
nerational transmission of disorganized mental
states in patients with AN, which could add to risk
for AN.
Attachment and Psychotherapy Processes and
Outcomes
Much of the research to date on attachment and
psychological interventions for eating disorders
comes from the work of Tasca et al. on day treat-
ment for BN, AN, and eating disorder not otherwise
specified (EDNOS), and on group therapy for BED.
These studies used self reports of attachment
styles. Pre-treatment attachment avoidance was
associated with dropping out of day treatment for
AN50 and dropping out of group cognitive behav-
ioral therapy (GCBT) for BED.51 Attachment avoid-
ance was also associated with problematic group
treatment processes. For example, greater attach-
ment avoidance in patients with BED was related
to a decreasing therapeutic alliance in group psy-
chodynamic interpersonal psychotherapy (GPIP).52
Attachment avoidance was also associated with
lower group cohesion in the day treatment of a
mixed diagnostic sample.53 Illing et al.53 suggested
that despite the apparent dismissiveness of those
with greater attachment avoidance, these patients
were likely highly sensitive to implicit group
714
therapy demands for closeness and cohesion, and
this may have precipitate their dropping out.
Higher pre-treatment attachment anxiety was
associated with poorer outcomes in the day treat-
ment of AN35,54 and in group therapy for those with
BED who received GCBT.51 Conversely, higher
attachment anxiety was associated with relatively
better treatment outcomes for those with BED if
they received GPIP. Follow up research indicated
that those with BED and higher attachment anxiety
may have required an increasing sense of group
engagement, cohesion, and alliance in order to
benefit from group treatment.52,55 Tasca
et al. 51,52,55
suggested that group treatment that
specifically focused on affect regulation, interper-
sonal sensitivities, and developing group cohesion
(i.e., GPIP), which are key elements of attachment
anxiety, may have made this treatment modality
more relevant and perhaps more effective for these
participants.
Only one small scale exploratory study associ-
ated the AAI to psychotherapy processes in an eat-
ing disorder sample.56 In that study, preoccupied
(anxiously attached) patients with BN had more
and longer speaking turns, and initiated speaking
more frequently than dismissing (avoidantly
attached) patients with BN. These findings suggest
that attachment states of mind as assessed by the
AAI may have an impact on the manner in which
patients with BN make use of psychotherapy. Evi-
dence from research on non-eating disorder
patient groups suggest that psychological treat-
ments can change attachment states of mind from
insecure to secure.57 Such research using the AAI in
a sample of those with eating disorders has not yet
been published. However, studies using self reports
in patients with BED suggest that attachment inse-
curity can improve up to 1 year post group treat-
ment.58,59 The effect of attachment states of mind
as assessed by the AAI on treatment processes and
outcomes in eating disorders remains an important
and largely untapped area of research.
Recommendations for Attachment Research in
Eating Disorders
Our examination of AAI research in eating disor-
ders highlighted the limited number of such stud-
ies. In addition, with one recent exception,29
sample sizes in these AAI studies are quite small.
We are aware of at least two research groups who
are currently conducting larger AAI studies in BN60
and BED.61 Psychotherapy research using the AAI
to assess change in attachment states of mind and
their interaction with treatment type will add to
International Journal of Eating Disorders 47:7 710–717 2014

our knowledge of treatment processes and out-
comes for those with eating disorders. Research on
the impact of reflective functioning and disorgan-
ized mental states on symptom maintenance and
severity will inform our understanding of potential
risk and maintenance factors for eating disorders.
However, due to the time and cost associated with
AAI research, we expect that the vast majority of
studies likely will continue to use self report meas-
ures of attachment.
Regardless of measurement approach, research
on the mechanisms by which attachment insecur-
ity affects the maintenance of eating disorder
symptoms would clarify the nature and impact of
attachment functioning, and would suggest targets
for interventions. To date, this research has been
cross sectional in nature. Prospective, longitudinal,
and case control studies are needed to truly under-
stand the potential risk for eating disorders con-
ferred by attachment insecurity and the
mechanisms by which this occurs. Further, the
roles of childhood adversity and family environ-
ment and their interaction with attachment inse-
curity could inform specific prevention and
treatment programs. Finally, research showed that
serotonin dysregulation may be a mechanism by
which attachment insecurity and/or childhood
adversity leads to BN symptoms.48 Such research
could point to potential gene by attachment envi-
ronment interactions that are detrimental for
women who binge eat.
Practice Implications
Individuals with eating disorders and attach-
ment avoidance or attachment anxiety have dif-
fering affect regulation approaches and
interpersonal styles that affect their interactions
with treatment providers and their behaviors in
therapy. Clinicians may consider assessing
attachment insecurity by self report or by inter-
view. Tasca et al.62 reference data on clinical and
non-clinical samples that clinicians can use to
help interpret self report and AAI scales. Peder-
sen et al.29 provide similar data for reflective
functioning among patients with BN.
Evidence-based treatment-oriented practice
reviews now exist for attachment insecurity in gen-
eral63 and for eating disorders in particular.62
Assessing and understanding a patient’s level and
quality of attachment insecurity could provide a
map for clinicians on how to personalize therapy
and therapeutic stances to optimize patient out-
comes. Individuals with attachment avoidance are
at risk for experiencing a decrease in the therapeu-
International Journal of Eating Disorders 47:7 710–717 2014
ATTACHMENT AND EATING DISORDERS
tic alliance and dropping out of treatment.50–52
Despite outward appearances these individuals are
highly sensitive and tend to react negatively to
pressures to self disclose, to bond with the thera-
pist or group, and to express emotions. Distress
caused by such pressures may precipitate prema-
ture treatment termination among those high in
attachment avoidance. Although in general these
patients may benefit from increasing their emo-
tional experiences and reducing interpersonal dis-
tance, they will require a therapeutic approach that
takes a graded and gradual approach to self disclo-
sure and affective expression. On the other hand,
those with greater attachment anxiety require an
early and ongoing sense of increased therapeutic
alliance or group cohesion to benefit from ther-
apy.51,52,55 However, often their attachment anxiety
interferes with their ability to be reflective and to
make the best use of treatment. Helping those with
greater attachment anxiety to distance from their
emotions may improve their mentalizing capacities
with regard to themselves and others. Improved
reflective functioning could help those with greater
attachment anxiety to take a step back from their
overwhelming anger, self loathing, and fears asso-
ciated with relationship loss.
In summary, although still relatively new, attach-
ment research in eating disorders has important clin-
ical utility by helping to inform clinicians on effective
therapeutic stances that are specific to type of patient
attachment insecurity. As indicated, longitudinal
research in community samples shows that attach-
ment insecurity and disorganization in infancy con-
fers greater risk for adult psychopathology in
general.5 Whether these elevate the specific risk for
an eating disorder is currently unknown, though
cross sectional research suggests mechanisms by
which attachment insecurity may affect eating disor-
der symptoms.37,44 Further, longitudinal research in
other samples has shown that biological vulnerabil-
ities likely interact with early attachment insecurity
and disorganization to confer risk for adult psycho-
pathology.64 Similarly, adult attachment insecurity
may interact with biological vulnerabilities for those
who binge eat.48 Research on attachment functioning
among those with eating disorders provides a prom-
ising avenue to further understand developmental
risk factors, symptom maintenance, and treatment
processes and outcomes.
Giorgio A. Tasca holds the Research Chair in Psycho-
therapy Research, University of Ottawa and The Ottawa
Hospital. The authors thank Livia Chyurlia for her help in
preparing the manuscript.
715
TASCA AND BALFOUR
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