Does attachment insecurity affect the outcomes of a multidisciplinary pain management program? The association between attachment insecurity, pain, disability, distress, and the use of opioids

doi:10.1016/j.socscimed.2012.01.009

Social Science & Medicine

Volume 74, Issue 9, May 2012, Pages 1461-1468

https://doi.org/10.1016/j.socscimed.2012.01.009 Get rights and content

Abstract

Cognitive and behavioural treatments have been shown to be effective for the management of chronic pain. However, not all patients succeed at such a treatment. Attachment insecurity has recently been proposed as an individual vulnerability factor that may have a negative impact on pain, disability, psychological distress, and compliance with treatment, resulting in a poorer outcome. Furthermore, attachment avoidance has been associated with opioid abuse. We hypothesised that attachment anxiety would be associated with higher levels of pain intensity and disability, and that both attachment dimensions would be associated with anxiety and depression. Moreover, we hypothesised that attachment avoidance would be positively associated with the use of opioids. Finally, we predicted that patients with an insecure attachment orientation would profit less from a routine pain management program. Data were collected from 72 patients referred consecutively from December 2008 to August 2009 to a 13-week pain management program at a Danish multidisciplinary pain centre. Both attachment dimensions were positively associated with anxiety and depression. Moreover, the insecurely attached patients used significantly more opioids compared to the securely attached. None of the attachment dimensions was associated with pain and disability, and the pain management program was equally effective for both the secure and insecure groups. However, the level of anxiety and depression for insecurely attached patients did not decline below a clinical level post-treatment. The present study suggests that attachment insecurity plays an important role in the context of chronic pain management. With regards to the management of pain related anxiety, depression, and the use of opioids, the current results suggests that practitioners should keep attachment insecurity in mind.

Highlights

► Attachment insecurity was a vulnerability factor in the context of chronic pain management. ► Insecurely attached patients used more morphine (mg/day) compared to their securely attached counterparts. ► Insecurely attached patients were more anxious and depressed both at pre-treatment and post-treatment, compared to their securely attached counterparts.

Introduction

Cognitive and behavioural treatments (CBT) are frequently used for various chronic pain conditions (Morley, Eccleston, & Williams, 1999). The main goal of most CBT programs for chronic pain is not eradication of pain symptoms but management of the pain condition. This includes efforts to increase planned activity, improve self-care and social relations while also aiming to progressively reduce pain medications. This is a collaborative process demanding active engagement by the patient. Effective outcome therefore relies on a trustworthy partnership between the patient and the healthcare provider and the acquisition of adaptive coping strategies. The process can leave some patients more vulnerable than others in succeeding at such a treatment as they may struggle to develop a trustworthy partnership or to develop adaptive coping strategies. Indeed, attachment insecurity has recently been proposed as an individual vulnerability factor that may have a negative impact on both pain (Meredith, Ownsworth, & Strong, 2008) and compliance with treatment, resulting in poorer treatment outcome in self-management regimens (Ciechanowski, Katon, Russo, & Walker, 2001). Moreover, attachment insecurity has been associated with poorer outcome (Hardy et al., 2001) and early drop out (Tasca et al., 2006) of time limited cognitive therapy.

Section snippets

Attachment theory

According to Bowlby (1969/1997) early relationship experiences result in the development of attachment orientations, which are characterized as complex cognitive-emotional schemas of the self and others. Attachment orientations are described as relatively stable schemas, which affect emotion regulation and our response to stressors and health behaviours (Maunder & Hunter, 2001). Furthermore, attachment insecurity has been associated with maladaptive adjustment to various chronic health

Attachment insecurity, pain, disability and psychological distress

Kolb (1982) was the first to directly apply attachment theory to pain in an attempt to explain pain behaviours in chronic pain patients. Kolb proposed that persistent pain complaining could be interpreted as an attachment behaviour, i.e., a cry for security. Later, Mikail, Henderson, and Tasca (1994) outlined a heuristic model explaining how the four attachment styles activate different help-seeking behaviours and adaptations to chronic pain. In particular, patients with high levels of

Attachment insecurity and the use of opioids

Recently, longstanding opioid use was found to be significantly associated with greater pain intensity and depression. In addition, withdrawal from opioid use has been associated with improvement in pain intensity and function (Townsend et al., 2008). Therefore, more knowledge about vulnerability factors for opioid use in chronic pain is important for the outcome of pain rehabilitation. To our knowledge, no previous studies have looked at the association between attachment insecurity and use of

Attachment insecurity and outcome of multidisciplinary pain management

A few studies have examined the role of attachment insecurity in relation to outcomes of multidisciplinary pain management (Ciechanowski et al., 2003, Meredith et al., 2007). In Ciechanowski et al. (2003), 111 patients were first assessed before admission to a 3–4 week multidisciplinary pain rehabilitation program and then at 12 months follow-up. It was found that those with a fearful attachment style (high levels of attachment anxiety and avoidance) had higher levels of depression at both

Hypotheses

We hypothesised that attachment anxiety would be associated with higher levels of pain intensity and disability, and that both attachment dimensions would be associated with higher levels of anxiety and depression. Furthermore, we hypothesised that attachment avoidance would be positively associated with the use of opioids (morphine mg/day). Finally, we hypothesised that patients with an insecure attachment orientation would profit less from the pain management program, measured on all the

Participants

Data were collected from 72 patients referred consecutively from December 2008 to August 2009 to a 13-week pain management program. Participants were referred for treatment at a Danish multidisciplinary pain centre. The service is a specialist tertiary one, receiving referrals from other pain clinics and from insurance companies. All patients were thoroughly assessed by a multidisciplinary team before admission. Competing somatic disorders led to exclusion. The team of specialists included

Results

The mean age of the patients was 43.2 years (SD = 8.9); 86.1% were female. The mean years of having had chronic pain was 8.8 years (SD = 7.1) and 35.2% were characterised as insecurely attached.

Discussion

Although hypothesised, it was not a surprise that attachment anxiety was not directly associated with pain intensity and disability given the previous inconsistent results (Andersen et al., 2011, Ciechanowski et al., 2003, Meredith et al., 2007). However, the hypothesis regarding the association between the attachment dimensions and anxiety and depression was confirmed. Similar to Ciechanowski et al. (2003) and Meredith et al. (2007), we found that both attachment dimensions were significantly

Acknowledgements

We would like to thank Allevia – Multidisciplinary Pain Centre, Denmark for supporting this study. In addition, we would also like to extend the gratitude to the professional staff at Allevia for conducting the pain rehabilitation according to the manualised program and for collecting the data.

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In the final study sample, comprising 973 patients (31.6%), we found an interaction between the attachment dimensions. Hence, the effect of attachment anxiety on PCS was statistically insignificant at low avoidance (25th percentile) but significant at high avoidance (75th percentile, β = 0.64 (95%CI: 0.02; 1.26)), whereas the effect of attachment avoidance was significant regardless of level of attachment anxiety (25th percentile, β = 1.09 (95%CI: 0.18; 2.01); 75th percentile, β = 2.71 (95%CI: 1.80; 3.61)).
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Taken together, these findings suggest that there are indeed mixed findings on the specific role of attachment within the experience and expression of pain. Although a number of studies have assessed the impact of attachment insecurity on health behaviors, outcomes, and treatment adherence [23–26], no study has to our knowledge specifically assessed the impact of attachment orientations on pain behaviors in experimental pain. Firstly, we hypothesized that attachment insecurity (high levels of attachment anxiety and/or attachment avoidance) would be associated with higher levels of pain during the cold pressor test.
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Does attachment insecurity affect the outcomes of a multidisciplinary pain management program? The association between attachment insecurity, pain, disability, distress, and the use of opioids

Abstract

Highlights

Introduction

Section snippets

Attachment theory

Attachment insecurity, pain, disability and psychological distress

Attachment insecurity and the use of opioids

Attachment insecurity and outcome of multidisciplinary pain management

Hypotheses

Participants

Results

Discussion

Acknowledgements

Pain

Clinical Psychology Review

Pain

Psychosomatics

Social Science & Medicine

Clinical Psychology Review

Pain

Pain

European Journal of Pain

Clinical Psychology Review

Pain

Journal of Psychosomatic Research

Clinical Psychology Review

Pain

The relationship between chronic whiplash-associated disorder and posttraumatic stress: attachment-anxiety may be a vulnerability factor

European Journal of Psychotraumatology

Attachment styles among young adults: a test of a four-category model

Journal of Personality and Social Psychology

Attachment and loss: Vol. I. Attachment

Attachment cognitions and college and work functioning two years later in adolescent women

Journal of Youth and Adolescence

The patient-provider relationship: attachment theory and adherence to treatment in diabetes

American Journal of Psychiatry

Statistical power analysis for the behavioral sciences