Pain 120 (2006) 4452

www.elsevier.com/locate/pain

The relationship of adult attachment to emotion, catastrophizing,

control, threshold and tolerance, in experimentally-induced pain
Pamela J. Meredith *, Jenny Strong, Judith A. Feeney
Division of Occupational Therapy, The University of Queensland, St Lucia Queensland, Brisbane, Queensland, 4072 Australia

Received 2 June 2005; received in revised form 30 September 2005; accepted 10 October 2005

Abstract
Although insecure attachment has been associated with a range of variables linked with problematic adjustment to chronic pain, the causal
direction of these relationships remains unclear. Adult attachment style is, theoretically, developmentally antecedent to cognitions, emotions
and behaviours (and might therefore be expected to contribute to maladjustment). It can also be argued, however, that the experience of
chronic pain increases attachment insecurity. This project examined this issue by determining associations between adult attachment
characteristics, collected prior to an acute (coldpressor) pain experience, and a range of emotional, cognitive, pain tolerance, intensity and
threshold variables collected during and after the coldpressor task. A convenience sample of 58 participants with no history of chronic pain
was recruited. Results demonstrated that attachment anxiety was associated with lower pain thresholds; more stress, depression, and
catastrophizing; diminished perceptions of control over pain; and diminished ability to decrease pain. Conversely, secure attachment was
linked with lower levels of depression and catastrophizing, and more control over pain. Of particular interest were findings that attachment
style moderated the effects of pain intensity on the tendency to catastrophize, such that insecurely attached individuals were more likely to
catastrophize when reporting high pain intensity. This is the first study to link attachment with perceptions of pain in a pain-free sample.
These findings cast anxious attachment as a vulnerability factor for chronic pain following acute episodes of pain, while secure attachment
may provide more resilience.
q 2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Keywords: Adult attachment theory; Acute pain; Catastrophizing; Coldpressor

There has been a great deal of interest in the process by
which acute pain becomes chronic (Aronoff & Feldman,
2000; Epping-Jordan et al., 1998; Young, 2003). In the
absence of adequate physiological and demographic
predictors of chronicity, the contributing roles of a range
of cognitive and behavioural factors have been extensively
investigated (Severeijns et al., 2005). Nevertheless, precise
mechanisms remain speculative.
Adult attachment theory has been proposed as a
developmental framework for chronic pain (Anderson &
Hines, 1994; Kolb, 1982; Mikail et al., 1994). In particular,
the negative cognitive dispositions, emotional distress, and
self-sabotaging behaviours associated with insecure attach-
ment, have been proposed to contribute to the etiology of
* Corresponding author. Tel.: C61 7 3365 2652; fax: C61 7 3365 1622.
E-mail address: p.meredith@uq.edu.au (P.J. Meredith).
0304-3959/$20.00 q 2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.pain.2005.10.008
chronic pain (Mikail et al., 1994). A critical assumption of
this proposition is that insecure attachment (and associated
maladaptive cognitions, behaviours and emotions) precedes
chronic pain and thus represents a vulnerability factor for
the development of chronic pain. Nevertheless, it might
equally be argued that the experience of chronic pain
promotes insecure attachment patterns. Hence, determining
associations between adult attachment and acute pain are an
important intermediate stage in understanding of the role of
attachment in the transition from acute to chronic pain.
The adult attachment literature recognizes two dimen-
sions of attachment reflecting comfort with closeness
(comfort) and anxiety over relationships (anxiety) (Feeney
et al., 1994; Fraley & Waller, 1998; Sanford, 1997).
Individuals display predictable patterns of cognitions,
behaviours and emotions consistent with high or low
comfort and high or low anxiety; hence, these two
dimensions define four attachment styles. These styles
 P.J. Meredith et al. / Pain 120 (2006) 4452 45

have been labeled secure, fearful, preoccupied, and Table 1

dismissingthe latter three recognized as insecure styles Demographic details
(Bartholomew & Horowitz, 1991). Extensive emotional, Variable NZ58 %
cognitive, behavioural and interpersonal correlates of these Marital status Married/facto 29 50
attachment styles have been empirically validated (Bartho- Separated/ 4 6.9
lomew, 1990; Ciechanowski et al., 2002; Cole-Detke & divorced
Kobak, 1996; Feeney & Ryan, 1994; Hazan & Shaver, Never married 24 41.4
Missing 1 1.7
1987; Hunter & Maunder, 2002; Mikulincer, 1995). Gender Male 22 37.9
Although adult attachment has not been explored in Female 36 62.1
relation to perceptions of acute pain, there is mounting Education Junior 3 5.2
evidence linking attachment and chronic pain variables. For Senior 3 5.2
example, for those in chronic pain, insecure attachment has Tafe 4 6.9
Graduate 29 50
been empirically associated with distress and suffering Post-graduate 19 32.8
(Pearce et al., 2001), depression, catastrophizing, and Employment Full-time 31 53.4
number of pain-related health care visits (Ciechanowski et Part-time 16 27.6
al., 2003), threat appraisal of the pain (Meredith et al., in Retired 2 3.4
Unempolyed/ 8 13.8
press), and physical and hypochondriacal symptoms
scholarship
(Schmidt et al., 2002) Missing 1 1.7
While these links continue to emerge in the literature, Income Less than $25, 12 20.7
most data are correlational in nature; hence, causality cannot 000
be confirmed. $25,000$35, 8 13.8
000
$35,000$45, 6 10.3
000
$45,000$55, 6 10.3
1. Research questions 000
$55,000$65, 3 5.2
000
This study was designed to explore the proposition More than $65, 22 37.9
that attachment styles and dimensions, measured prior to 000
an acute pain experience, would impact on perceptions of Missing 1 1.7
pain. In particular, those reporting insecure patterns of Attachment Secure 29 50
Fearful 7 12.1
attachment were expected to have lower pain thresholds
Preoccupied 3 5.2
and lower pain tolerance, and to perceive higher levels of Dismissing 16 27.6
pain intensity, compared to secure individuals. Because Missing 3 5.2
of the abundant evidence associating catastrophizing,
perceptions of control, and emotional variables, with both
pain (Severeijns et al., 2005) and attachment (Ciecha- 2.2. Procedure
nowski et al., 2003), these variables were also included
as covariates in the study. It was predicted that Participants were sought from among students at the
attachment anxiety would be associated with catastro- University of Queensland, as well as friends and
phizing, control and emotional variables. colleagues of the researchers. Most participants
responded to a written or oral invitation from the first
researcher who also performed the testing. Participation
was voluntary, and ethical clearance for the project was
2. Methods obtained from The University of Queenslands Beha-
vioural and Social Science Ethical Review Committee.
2.1. Participants No incentive was provided for participation. Subjects
received an information sheet and consent form, and
A total of 58 people agreed to participate in this research, completed a written questionnaire prior to undergoing the
from a potential sample of 80. This represents an acceptance coldpressor task. They were then given detailed verbal
rate of 72.5%. Of these, 22 were men and 36 were women. A instructions before participating in the task. Finally, a
summary of demographic details is presented in Table 1. brief post-task questionnaire was completed. Participants
Overall, the majority of participants were Australian, were then offered the opportunity to ask any questions
married, university graduates, and employed full-time. All about the task or the research, and were advised that a
were aged between 21 and 69 years, with a mean age of 36 summary of results would be made available on
years (see Table 2). completion of the study.
46 P.J. Meredith et al. / Pain 120 (2006) 4452

Table 2 have been reported (Crawford & Henry, 2003; Lovibond &
Descriptive data Lovibond, 1993), internal consistency, temporal stability,
Variable Mean SD Range and convergent and discriminant validity, are excellent, and
Age 35.69 years 12.24 2169 years a consistent factor structure has been found (Brown et al.,
Secure 4.89 1.42 17 1997; Clara et al., 2001). Sample items include: I found it
Fearful 2.93 1.74 17 hard to wind down (stress), I experienced trembling
Preoccupied 2.39 1.46 17 (anxiety), and I could not seem to experience any positive
Dismissing 4.14 1.89 17
feeling at all (depression). Reliability scores in the present
Attachment 72.27 17.49 27123
avoidance project were .80 for the stress scale, .57 for the anxiety scale,
Attachment 38.23 8.58 1962 and .84 for the depression scale. As a result of the low
anxiety reliability finding for anxiety, this scale was removed from
Threshold 55.88 s 76.25 3240 s further analyses.
Tolerance 173.93 s 86.85 16240 s
The Relationship Questionnaire (RQ, Bartholomew &
Average pain 53.28 21.85 10100
intensity Horowitz, 1991)pre-task. In this self-report questionnaire
Overall pain 5.02 2.59 010 an individual selects one of four paragraphs, representing
intensity secure, preoccupied, fearful-avoidant, or dismissive-avoi-
Minimum VAS 33.22 25.45 0100 dant attachment styles. In addition, participants rate, on a
Maximum VAS 65.67 22.45 11100
seven-point scale (where 1Znot at all like me, and 7Zvery
1 min VAS 47.64 26.15 5100
Stress 10.17 7.52 030 much like me), the extent to which they believe each
Depression 4.83 6.53 034 attachment style reflects their general relationship style. The
Average 1.04 .93 03.5 RQ is a widely used measure of attachment showing
catastrophizing adequate predictive validity and test-retest reliability
Control 3.97 .96 26
(Herzberg et al., 1999; Scharfe & Bartholomew, 1994).
Decrease pain 3.71 .97 26
Average post- .86 1.08 04.2 Attachment Style Questionnaire (ASQ, Feeney et al.,
catastrophizing 1994)pre-task. This self-report measure of adult attach-
Post-control 4.02 1.47 06 ment style identifies two major attachment dimensions:
Post-decrease 3.02 1.59 06 discomfort with closeness (or avoidance) and anxiety over
pain
relationships (anxiety). Participants rate 40 items on a six-
point scale (1Ztotally disagree to 6Ztotally agree). In the
2.3. Apparatus and measures present study, alpha coefficients for the two dimensions
were .92 (discomfort) and .82 (anxiety), with scales
The coldpressor used in this study was an insulated consisting of 27 and 12 items respectively. An example of
container divided into two compartments by wire mesh, a discomfort item is: I prefer to keep to myself, while a
with ice on one side and ice-free chilled water on the other. sample anxiety item is: It is important to me that others like
The tank was tall enough for the entire forearm to be me.
immersed. Water was maintained at 2 8C, and was Coping Strategies QuestionnaireCatastrophizing
circulated by a submerged pump which was switched off Subscale (CSQ-Cat, Rosenstiel & Keefe, 1983)pre-
during testing (Bandura et al., 1987; Geisser et al., 1992). task and post-task. The catastrophizing subscale is a
Instructions for use of the coldpressor were standard for 6-item self-report measure of pain catastrophizing
each participant. Although participants were not informed (Swartzman et al., 1994). Participants rate items on a
prior to the task, there was a four-minute ceiling. seven-point scale (0Znever do that to 6Zalways do that).
Coldpressor measures are described below. A sample item is: It is terrible and I feel it is never going
Participants provided several demographic details to get any better. The pre-treatment catastrophizing alpha
including age, gender, marital status, income, education, coefficient was .87, while post-treatment alpha was .90.
employment status, and country of origin. In addition, Prior to the task, individuals were instructed to indicate
several questionnaires were completed prior to the how much you engage in that activity when you feel
coldpressor task, along with measures during, and a further pain, while after the task participants were asked to
brief questionnaire after, the task. Measures included: indicate how much you engaged in that activity during
Depression Anxiety Stress Scales 21(DASS21, Lovibond the current experimental task. In addition, prior to testing,
& Lovibond, 1993; 1995)pre-task. This 21-item ques- patients rated how much control they believe they would
tionnaire is a brief version of the 42-item DASS. have over the pain (0Zno control, to 6Zcomplete
It comprises three scales of seven items (stress, depression, control) and how successful they would be in decreasing
and anxiety). Questions are scored on a four-point scale their pain (0Zcannot decrease it at all, to 6Zcan decrease
(0Zdid not apply to me at all, to 3Zapplied to me very it completely). After the task they used the same scales to
much or most of the time) based on the previous week. record how much control of, and ability to decrease, the
Adequate reliability, convergent and discriminant validity pain they actually did have.
 P.J. Meredith et al. / Pain 120 (2006) 4452
Coldpressor ThresholdThis was the amount of time (in
seconds) after commencing the task that the individual
reported experiencing pain, recorded with a stopwatch.
Coldpressor ToleranceThis was the total period of
time (in seconds) that the individual tolerated immersion in
the water, recorded with a stopwatch.
Pain IntensitySeveral measures of pain intensity were
adopted during and after the task. Pain ratings were
collected at 20-s intervals during the activity (12 scores
over 4 min), and these results were averaged to determine
Average Pain Intensity. Scores representing minimum and
maximum pain ratings were also documented from these
results. Overall Pain Intensity was indicated on the post-task
questionnaire by requesting the participant to mark, on a 10-
point scale (0Zno pain, to 10Zpain as bad as it could be),
how painful they rated the coldpressor task overall.
3. Results
3.1. Statistics
Analyses were undertaken using SPSS 13.0. Missing data
resulted in a slightly decreased N for some analyses.
A power plot showing power as a function of effect size was
generated (Cohen, 1988). This suggests that, with 58
participants and a power of 0.8, a moderate effect size
should be detected. Data checking strategies revealed no
outliers, and 11 skewed variables. Ten variables were
positively skewed (age, pre- and post-catastrophizing,
fearful and preoccupied attachment, stress and depression,
threshold, minimum pain intensity, and average pain
intensity), and these were transformed using logarithmic
transformations. One variable (secure attachment) was
negatively skewed, and was therefore reflected before
being transformed logarithmically. Because results using
the transformed variables did not differ substantially from
those based on untransformed variables, only original
analyses are reported in this paper. Unless otherwise
stated, the words secure, fearful, preoccupied, and
dismissing refer to continuous RQ variables. Categorical
RQ variables are designated as such.
3.2. Demographic and descriptive details
Descriptive details for continuous variables are provided
in Table 2. It is interesting to note the wide range in the
threshold and tolerance variables, highlighting the relatively
subjective nature of pain perceptions. Age was included in
correlation analyses (see results below) and, because it was
linked with both attachment and pain threshold variables, it
was included as a covariate in further analyses. A series of
ANOVAs revealed that gender was related to secure
attachment (F(1, 55)Z4.61, PZ.04) and attachment
avoidance (F(1, 53)Z15.04, P!.001). Inspection of
47
the means revealed that women reported being more secure
and less avoidant than males in the sample.
3.3. Correlations among variables
Correlations among the four continuous RQ attachment
scales, two ASQ dimensions, and all other variables are
presented in Table 3. Secure attachment was linked with
lower age, more stress and control over pain prior to the
task, and less catastrophizing (both pre- and post-task).
Fearful attachment was related to more pre-task catastro-
phizing, and lower ratings of pain intensity at one minute.
Preoccupied attachment was related to increased pre-task
catastrophizing, and less control over the pain after the task.
Dismissing attachment was not associated with any of the
variables.
ASQ discomfort with closeness was positively correlated
only with age. ASQ anxiety over relationships, on the other
hand, was linked with more pre-task catastrophizing, stress,
and depression, and lower pre-task control over pain, pre-
task ability to decrease pain, and pain threshold. Age was
negatively associated with anxiety over relationships.
Attachment variables were predictably linked together.
The low correlation between pre- and post-catastrophizing
is particularly noteworthy.
3.4. Associations between RQ attachment categories
and other variables
A series of one-way ANOVAs were conducted with the
categorical RQ attachment as the independent variable and
each of the other variables as dependent variables.
Attachment categories were significantly associated
with pre-task catastrophizing (F(3, 51)Z3.8, PZ.02), age
(F(3, 51)Z2.77, PZ.05), and depression (F(3, 51)Z3.4,
PZ.03). Post hoc analyses revealed that those reporting
dismissing attachment were older than other participants,
and were significantly more depressed (PZ.03) than those
reporting secure attachment styles. Although not reaching
significance, the extent of catastrophizing reported by
dismissing participants was lower compared to those
indicating fearful or preoccupied attachment. In general,
secure individuals were less depressed and catastrophized
less than the other styles, with two findings reaching
significance (see Table 4). There were no significant
findings for pain intensity, threshold or tolerance variables.
With age included as a covariate in these analyses, and
incorporating interaction terms, the associations between
depression and attachment (PZ.63) and catastrophizing and
attachment (PZ.07) were no longer statistically significant.
Parameter estimates compared three categories of the RQ
variable with the fourth category (dismissing), revealing
that the fearful attachment category (BZ22.54, tZ2.65,
PZ.01) was significantly more strongly associated with
catastrophizing relative to the dismissing category. Accord-
ing to parameter estimates, fearful attachment also
48 P.J. Meredith et al. / Pain 120 (2006) 4452

Table 3
Intercorrelations between the variables

Variable 1 2 3 4 5 6 7 8 9
1 RQ secure 1
2 RQ fearful .10 1
3 RQ preocc K.01 .26* 1
4 RQ dismiss K.23 .04 K.14 1
5 Discomfort K.56*** .28* .12 .26* 1
6 Anxiety K.04 .18 .38** K.41** .002 1
7 Stress .26* .10 K.05 K.01 K.09 .38** 1
8 Depression K.20 .20 .23 .20 .22 .33** .53*** 1
9 Catastroph K.40** .31* .33** .07 .23 .46*** .18 .34** 1
10 Control .27* .01 K.08 .09 K.02 K.27* K.04 K.12 K.38**
11 Y Pain .07 .05 K.04 .19 .02 K.31* K.11 K.11 K.23
12 Post-catast K.30* .14 .09 K.08 .19 .20 .02 .10 .19
13 Post-contr .24 K.17 K.29* K.04 K.06 K.19 .11 K.22 K.28*
14 Post Y pain .20 K.14 K.09 K.09 K.04 .04 .08 K.18 K.07
15 Threshold .08 K.01 K.20 .02 K.05 K.34** K.18 K.19 K.16
16 Tolerance .09 K.06 K.07 K.05 .01 K.13 K.02 K.14 .04
17 VAS one .02 K.32* K.18 .07 .05 K.01 .33* .11 K.17
minute
18 VAS .002 .05 .17 K.12 K.04 .12 K.01 .001 K.04
19 Ave VAS K.001 K.19 .07 K.04 K.06 .11 .19 .07 K.07
20 Min pain .07 K.12 .16 K.02 K.05 .09 .18 .15 K.11
21 Max pain K.11 K.10 .006 K.05 .08 .21 .20 .14 .05
22 Age K.30* K.12 K.15 .19 .30* K.36** .02 .07 K.13

*, !.05; **, !.01; ***, !.001.

interacted with age in predicting catastrophizing (BZK.48, reporting preoccupied attachment were less able to decrease
tZK2.3, PZ.03) relative to dismissing attachment. Thus, pain relative to older, dismissing individuals.
those who were both younger and fearfully attached were
more inclined to catastrophize relative to older, dismissing 3.5. Continuous attachment variables as predictors
individuals. of pain variables
In addition, several new significant findings emerged
with the inclusion of age as a covariate. First, the categorical In order to explore in more depth the associations
RQ variable approached significance (F(3, 54)Z2.61, PZ between attachment and pain variables, further attention
.06) as a predictor of overall pain intensity; inspection of was given to the two instances in which attachment was
parameter estimates revealed that secure attachment significantly correlated with pain variables: ASQ anxiety
contributed significantly to overall pain intensity (BZ with pain threshold, and RQ fearful with pain intensity.
6.49, tZ2.57, PZ.01) compared with the dismissing Correlated variables were used as predictors of pain
category. The RQ variable and age also interacted to predict threshold and intensity; however, since the notion of
overall pain intensity (F(3, 54)Z2.81, PZ.05), with the prediction presumes that the independent variable precedes
interaction between secure attachment and age (BZK.10, the dependent variable, only measures taken prior to the
tZK2.74, PZ.01) emerging as significantly more strongly coldpressor task were considered as predictors. In the first
associated with pain intensity compared to dismissing case, only ASQ anxiety and pre-control were correlated
attachment. Thus, people who were both older and securely with pain threshold. These two variables were entered as
attached reported less pain relative to younger, dismissing independent variables in a regression analysis with pain
individuals. threshold as the dependent variable, revealing a significant
Second, categorical RQ predicted post-ability to decrease Table 4
pain (F(3, 52)Z2.75, PZ.05), with preoccupied attachment Summary of means of attachment categories for significant ANOVAs
revealed as more strongly associated with ability to decrease
Variable Secure M Fearful M Preoccupied Dismissing
pain (BZK15.50, tZK2.12, PZ.04) compared with M M
dismissing attachment. RQ also interacted with age in
N 29 7 3 16
predicting this variable (F(3, 52)Z3.44, PZ.03), with the Pre-cata- 4.7* 10.6* 12.3 6.4
interaction between the preoccupied category and age (BZ strophizing
.61, tZ2.12, PZ.04) emerging as significantly more Age 33.4 34.7 34.3 41.7
strongly related with post-ability to decrease pain compared Depression 2.4* 7.1 7.3 8.1*
with dismissing attachment. Thus, younger participants *Denotes significant difference P!.05 using Bonferroni Post Hoc analyses.

overall result (F(2, 52)Z5.4, PZ.007). Attachment anxiety
contributed uniquely to this relationship (tZK2.12, PZ
.04), although control almost reached significance (PZ.07).
Including age as a covariate in this equation slightly
decreased the overall significance (F(3, 53)Z4.24, PZ
.009).
In the second case, RQ fearful and stress were entered as
independent variables to predict pain intensity ratings at
1 min. A significant overall result was obtained (F(2, 43)Z
7.71, PZ.001), with both variables contributing signifi-
cantly to the relationship (tZK2.73, PZ.009 and tZ3.07,
PZ.004 respectively). Including age as a covariate again
decreased the significance of this equation (F(3, 42)Z5.03,
PZ.005).
3.6. Post-catastrophizing
Because of the different correlation pattern between pre-
and post-task catastrophizing, and because post-catastro-
phizing was so strongly associated with all pain variables, it
was explored further. With all correlated variables (secure
attachment, tolerance, threshold, post-control, post-ability
to decrease pain, minimum and maximum pain intensity,
and average and overall pain intensity scores) entered as
independent variables and post-catastrophizing as the
dependent variable, a significant result was obtained (F(9,
44)Z6.9, P!.001), with secure attachment and overall pain
intensity the only contributing variables (tZK2.97, PZ
.005, and tZ3.17, PZ.003 respectively). Due to the very
small degrees of freedom in this analysis, it was repeated
using only the two significant variables (secure attachment
and pain intensity) as independent variables. These two
variables together explained 49% of the variance in post-
catastrophizing (F(2, 52)Z27.06, P!.001). Inclusion of
neither age nor pre-catastrophizing as covariates enhanced
these results, nor emerged as significant predictors.
security moderates pain and catastrophizing
1.2
1.0
0.8
post-track catastrophizing
0.6
0.4
0.2
0.0
0.2
0.4
0.6
0.8
Low Medium
overall pain intensity
Fig. 1. Moderation of attachment security on relationship between pain
intensity and post-task catastrophizing.
P.J. Meredith et al. / Pain 120 (2006) 4452 49
Following from these results, and because it is
theoretically plausible that secure attachment may moderate
the effect of pain on catastrophizing, this hypothesis was
explored. Indeed, a regression analysis (incorporating an
interaction term) revealed a significant interaction between
secure attachment and overall pain intensity in predicting
post-catastrophizing (F(1, 54)Z11.55, PZ.001). These
three variables were standardized and, using ModGraph
(Jose, 2005), a continuous moderator chart was developed
using standardized variables (see Fig. 1). This chart revealed
that those high in secure attachment consistently catastro-
phized less than did those lower in secure attachment.
Further, for participants who reported low levels of pain in
response to the coldpressor task, levels of catastrophizing
were similar for all levels of secure attachment. As pain
increased, however, attachment security gained importance,
with those lowest in security reporting highest catastrophiz-
ing scores, while those high in security reported low
catastrophizing even for high levels of pain.
4. Discussion
These findings offer preliminary support for the role of
adult attachment variables in the perception of, and response
to, experimentally induced pain. Secure participants were
younger and more stressed; however, they reported less
depressive symptoms and less catastrophizing both before
and after the coldpressor task. They also perceived more
control over their pain. These factors are considered
adaptive or protective for coping with pain. Fearful
individuals reported more pre-task catastrophizing and,
together with stress, fearful attachment contributed signifi-
cantly to predictions of pain intensity at one minute.
Notably, although fearful attachment was hypothesised to
contribute to increased pain sensitivity, this sample
indicated less pain intensity at one minute of the task.
This finding should be considered with caution, however,
since fearful attachment was not related to any other
security
intensity variables. This may reflect a chance occurrence, or
High a social desirability bias whereby fearful participants strive
Medium
Low to appear to be coping well, stoically maintaining the
deception for 1 min.
Those high in preoccupied attachment were more likely
to catastrophize and to report less control of their pain after
the task. Dismissing attachment was associated with higher
levels of depression and less pre-task catastrophizing. These
findings are consistent with the hypotheses, and together
portray attachment security as an adaptive trait, while
insecure characteristics appear to constitute a vulnerability
to pain. The moderating impact of age on the associations
between the categorical attachment measure and pain
High
variables is interesting. Incorporating age decreased
associations between attachment/depression and attach-
ment/catastrophizing, suggesting that age accounted for a
considerable portion of this association. In addition, several
50 P.J. Meredith et al. / Pain 120 (2006) 4452
interesting significant interactions between attachment and
age emerged. Firstly, those who were both younger and
fearfully attached were more inclined to catastrophize
relative to older, dismissing individuals. Secondly, people
who were both older and securely attached reported less
pain relative to younger, dismissing individuals. Finally,
younger participants reporting preoccupied attachment were
less able to decrease pain relative to older, dismissing
individuals. Thus, there was a tendency for youth and
insecure attachment to be associated with less adaptive
variables.
Using ASQ attachment dimensions, anxiety over
relationships was more strongly linked with pain variables.
Anxious individuals reported increased catastrophizing,
stress and depression, and perceived less control of, and
ability to decrease, pain. Those scoring higher on this
dimension also reported experiencing pain earlier in the task
than those indicating lower attachment anxiety. Indeed,
attachment anxiety emerged as the sole unique predictor of
pain threshold, although this relationship diminished when
controlling for age. Thus, attachment anxiety was associated
with maladaptive coping cognitions, emotional distress, and
lowered pain thresholds, all of which are associated with
problematic adjustment to acute pain.
Variations in findings between the two attachment
measures employed in this study, and the relatively low
(but conceptually congruent) correlations between them,
warrant comment. Measures of attachment differ funda-
mentally in their approach to attachment issues (Feeney
et al., 1994), with ongoing debate regarding the clinical and
empirical value of attachment dimensions versus categories
(Fraley & Spieker, 2003a,b; Fraley & Waller, 1998).
Although secure attachment is theoretically comprised of
low discomfort with closeness and low anxiety over
relationships, evidence suggests that attachment patterns
are largely continuous rather than categorical. While such
conceptual and measurement differences presuppose vari-
ations in findings, one area of consistency between measures
is noteworthy: catastrophizing was linked with anxiety over
relationships and each of the anxious attachment styles
(fearful and preoccupied).
Previous research using the coldpressor task has revealed
associations between depressed mood and both decreased
pain tolerance (Gormsen et al., 2004; Zelman et al., 1991),
and increased pain threshold and tolerance (Geisser et al.,
2003). The finding that mood was largely unrelated to the
pain variables in the present study, may reflect a ceiling
effect due to the relatively low levels of stress and
depression in this healthy sample. The links observed
between mood and attachment warrant further consider-
ation, however. Associations between depression and
insecure attachment raise the possibility that, when faced
with chronic, unremitting pain, negative emotional ten-
dencies may be activated more strongly in those with
insecure attachment patterns, thus increasing the vulner-
ability of these individuals.
As noted, pre-task catastrophizing was positively
associated with all three anxious attachment variables
(fearful, preoccupied, anxious), and negatively with secure
attachment. This result is consistent with previous research,
and is in accord with predictions. Although pre-task
catastrophizing was associated with increased depression
and perceived inability to control pain, it was not associated
with any of the pain intensity variables. This finding is
contrary to initial expectations, and contradicts existing
evidence that high levels of catastrophizing predict
increased pain intensity (Severeijns et al., 2005). One
explanation is that measurement of pain catastrophizing
associated with hypothetical pain (pre-task) may draw more
on tendencies that might more accurately reflect attachment
characteristics, compared with measures of catastrophizing
associated with real pain. This would also explain the low
correlation between pre- and post-catastrophizing. Further
support for this suggestion was provided by the links
between post-task catastrophizing (which particularly
referenced the coldpressor pain) and all pain intensity
variables.
It was revealed that attachment security moderated the
relationship between pain intensity and post-catastrophiz-
ing, such that the impact of attachment security on
catastrophizing was most pronounced for participants who
reported high levels of pain in response to the coldpressor
task. Although this study does not address the direction of
the relationship between pain intensity and pain catastro-
phizing, Dixon et al. (2004) suggested that this relationship
may be circular (i.e. catastrophic thoughts influence
perceptions of pain severity which may, in turn, influence
catastrophic thinking). Findings of the present study, then,
are particularly interesting as they suggest that those
reporting insecure attachment tendencies may be at more
risk of escalating the catastrophizing/pain intensity spiral.
With catastrophizing known to contribute to chronicity
(Severeijns et al., 2005), this finding warrants further
empirical attention.
Several forms of bias may have been introduced to the
study. Firstly, selection bias may have been introduced as a
result of using a convenience sample. Use of students,
friends and colleagues as participants posed potential threats
to validity and generalizeability of findings, and confidence
in the relevance of results awaits replication with a more
diverse sample. Nevertheless, convenience samples of
students are typically represented in acute pain research
(e.g. Dixon et al., 2004), and inclusion of friends and
colleagues along with students in the present study may
actually have added diversity to this mix.
Since the researcher conducting the coldpressor task was
not blind to the purposes of the study, researcher bias may
have been introduced. Efforts to minimize this bias were
made by not viewing or scoring questionnaires until after
the task; hence, researchers were blind to attachment status
and catastrophizing scores of participants. In addition, due
mainly to the size of the literature and complexity of
 P.J. Meredith et al. / Pain 120 (2006) 4452
the findings regarding gender, no efforts were made to
control for participant or experimenter gender, which has
been shown to be associated with both pain and attachment
(Kallai et al., 2004).
Neglecting to consider social desirability responding
might also be considered a weakness of this project.
Experimental participants have been thought to try to be
more pain tolerant in order to be perceived as good
subjects (Geisser, 2004), and measurement of attachment
is known to be influenced by social desirability
responding (Leak & Parsons, 2001). Although Geisser
et al. (1992) found no relationships between measures of
social desirability and either pain threshold or tolerance
of a coldpressor task, these results warrant further
consideration in light of attachment variables. Repetition
of this project with a larger, more random sample of
participants, incorporating a social desirability measure,
and examining gender effects, would address many of
these concerns.
5. Conclusion
Results of this study provide mixed support for the
hypotheses. As predicted, insecure (anxious) attachment
was associated with lower pain thresholds. Contrary to
expectations, attachment was not directly associated with
pain tolerance, and only conservatively with pain intensity.
Nevertheless, attachment security moderated the effect of
pain intensity on post-task catastrophizing scores,
suggesting that low attachment security is likely to escalate
the pain/catastrophizing cycle, with concomitant impli-
cations for emotional distress, fear-avoidance, disability,
and chronicity. The findings of this study support the role of
attachment theory as a valuable heuristic in the field of pain,
and highlight the possible role of insecure attachment as a
vulnerability factor for acute pain experiences. Further
research in this field is warranted in order to address the role
of adult attachment in the transition from acute to chronic
pain.
Acknowledgements
The authors would like to acknowledge the generosity of
friends, students, and colleagues who agreed to participate
in this research, and the valuable contributions of two
anonymous reviewers. The statistical advice of Dr Ross
Darnell has also been appreciated. This research was
supported by a joint scholarship from the Graduate School
Postgraduate Research Studies Unit and the School of
Health and Rehabilitation Sciences at the University of
Queensland, Australia.
51
References
Anderson DJ, Hines RH. Attachment and pain. In: Grzesiak RC,
Ciccone DS, editors. Psychosocial vulnerability to chronic pain. New
York: Springer; 1994. p. 13752.
Aronoff GM, Feldman JB. Preventing disability from chronic paina
review and reappraisal. Int Rev Psychiatry 2000;12(2):15769.
Bandura A, OLeary A, Taylor CB, Gauthier J, Gossard D. Perceived self-
efficacy and pain control: opioid and nonopioid mechanisms. J Pers Soc
Psychol 1987;53(3):56371.
Bartholomew K. Avoidance of intimacy: an attachment perspective. J Soc
Pers Relat 1990;7:14778.
Bartholomew K, Horowitz LM. Attachment styles among young adults: a
test of a four-category model. J Pers Soc Psychol 1991;61:22644.
Brown TA, Chorpita BE, Korotitsch W, Barlow DH. Psychometric
properties of the Depression Anxiety Stress Scales (DASS) in clinical
samples. Behav Res Ther 1997;35(1):7989.
Ciechanowski PS, Walker EA, Katon WJ, Russo JE. Attachment theory: a
model for health care utilization and somatization. Psychosom Med
2002;64:6607.
Ciechanowski PS, Sullivan M, Jensen M, Romano J, Summers H. The
relationship of attachment style to depression, catastrophizing and
health care utilization in patients with chronic pain. Pain 2003;104:
62737.
Clara IP, Cox BJ, Enns MW. Confirmatory factor analysis of the
DepressionAnxietyStress Scales in depressed and anxious patients.
J Psychopathol Behav Assess 2001;23(1):617.
Cohen J. Statistical power analysis for the behavioural sciences. 2nd ed.
Hillsdale, NJ: Erlbaum; 1988.
Cole-Detke H, Kobak R. Attachment processes in eating disorder and
depression. J Consult Clin Psychol 1996;64(2):28290.
Crawford JR, Henry JD. The Depression Anxiety Stress Scale (DASS):
normative data and latent structure in a large non-clinical sample. Br
J Clin Psychol 2003;42(2):11131.
Dixon KE, Thorn B, Ward C. An evaluation of sex differences in
psychological and physiological responses to experimentally-induced
pain: a path analytic description. Pain 2004;112(12):18896.
Epping-Jordan JE, Wahlgren DR, Silliams RA, Pruitt SD, Slater MA,
Patterson TL, Grant I, Webster JS. Transition to chronic pain in men
with low back pain: predictive relationships among pain intensity,
disability, and depressive symptoms. Health Psychol 1998;17(5):4217.
Feeney JA, Ryan SM. Attachment style and affect regulation: relationships
with health behaviour and family experiences of illness in a student
sample. Health Psychol 1994;13:33445.
Feeney JA, Noller P, Hanrahan M. Assessing adult attachment. In: Sperling MB,
Berman WH, editors. Attachment in adults: clinical and developmental
perspectives. New York: Guilford Publications; 1994. p. 12852.
Fraley RC, Spieker SJ. Are infant attachment patterns continuously or
categorically distributed? A taxometric analysis of strange situation
behaviour Dev Psychol 2003a;39(3):387404.
Fraley RC, Spieker SJ. What are the differences between dimensional and
categorical models of individual differences in attachment? Reply to
Cassidy (2003), Cummings (2003), Sroufe (2003), and Waters and
Beauchaine (2003) Dev Psychol 2003b;39(3):4239.
Fraley RC, Waller NG. Adult attachment patterns: a test of the typological
model. In: Simpson JA, Rholes WS, editors. Attachment theory and
close relationships. New York: Guilford Press; 1998. p. 77114.
Geisser ME. The influence of coping styles and personality traits on
pain. In: Dworkin RH, Breitbart WS, editors. Psychosocial aspects
of pain: a handbook for health care providers. Progress in pain
research and management, vol. 27. Seattle, WA: IASP Press; 2004.
p. 52145.
Geisser ME, Robinson ME, Pickren WE. Differences in cognitive coping
strategies among pain-sensitive and pain tolerant individuals on the
cold-pressor test. Behav Ther 1992;23(1):3141.
52 P.J. Meredith et al. / Pain 120 (2006) 4452
Geisser ME, Casey KL, Brucksch CB, Ribbens CM, Appleton BB,
Crofford LJ. Perception of noxious and innocuous heat stimulation
among healthy women and women with fibromyalgia: association with
mood, somatic focus, and catastrophizing. Pain 2003;102:24350.
Gormsen L, Ribe AR, Raun P, Rosenberg R, Videbech P, Vestergaard P,
Bach FW, Jensen TS. Pain thresholds during and after treatment for
severe depression with electroconvulsive therapy. Eur J Pain 2004;8:
48793.
Hazan C, Shaver PR. Romantic love conceptualized as an attachment
process. J Pers Soc Psychol 1987;52:51124.
Herzberg DS, Hammen C, Burge D, Daley SE, Davila J, Lindberg N.
Attachment cognitions predict perceived and enacted social support
during late adolescence. J Adolesc Res 1999;14(4):387404.
Hunter JJ, Maunder RG. Using attachment theory to understand illness
behaviour. Gen Hosp Psychiatry 2002;23:17782.
Jose PE. Moderation/Mediation Help Centre, Version 1.0. School of
Psychology, Victoria University of Wellington; June 2004. Available
at: http://www.vuw.ac.nz/psyc/staff/pauljose/files/helpcentre/help1_in-
tro.php [Accessed 21 May, 2005].
Kallai I, Barke A, Voss U. The effects of experimenter characteristics on
pain reports in women and men. Pain 2004;112:1427.
Kolb LC. Attachment behavior and pain complaints. Psychosomatics 1982;
23:41325.
Leak GK, Parsons CJ. The susceptibility of three attachment style measures
to socially desirable responding. Soc Behav Personal 2001;29(1):
2130.
Lovibond PF, Lovibond SH. Manual for the Depression Anxiety Stress
Scales (DASS). Psychology foundation monograph; 1993 [Available
from The Psychology Foundation, Room 1005 Mathews Building,
University of New South Wales, 2052, Australia].
Lovibond PF, Lovibond SH. The structure of negative emotional states:
comparison of the Depression Anxiety Stress Scales (DASS) with the
Beck depression and anxiety inventories. Behav Res Ther 1995;33(3):
33553.
Meredith PJ, Strong J, Feeney JA. Evidence of a relationship between adult
attachment variables and appraisals of chronic pain. Pain Res Manag in
press.
Mikail SF, Henderson PR, Tasca GA. An interpersonally based model of
chronic pain: an application of attachment theory. Clin Psychol Rev
1994;14:116.
Mikulincer M. Attachment style and the mental representation of the self.
J Pers Soc Psychol 1995;69:120315.
Pearce S, Creed P, Cramond T. Attachment style and chronic pain
syndrome. Aust Pain Soc Newsl 2001;May:24.
Rosenstiel AK, Keefe FJ. The use of coping strategies in chronic low back
pain patients: relationship to patient characteristics and current
adjustment. Pain 1983;17(1):3344.
Sanford K. Two dimensions of adult attachment: further validation. J Soc
Pers Relat 1997;14(1):13343.
Scharfe E, Bartholomew K. Reliability and stability of adult attachment
patterns. Pers Relationships 1994;1:2343.
Schmidt S, Strauss B, Braehler E. Subjective physical complaints and
hypochondriacal features from an attachment theoretical perspective.
Psychol Psychother 2002;75:31332.
Severeijns R, van den Hout MA, Vlaeyen YWS. The causal status of pain
catastrophizing: an experimental test with healthy participants. Eur
J Pain 2005;9:25765.
Swartzman LC, Gwadry FG, Shapiro AP, Teasell RW. The factor structure
of the Coping Strategies Questionnaire. Pain 1994;57(3):3116.
Young CW. Transition from acute to chronic pain: a biopsychosocial model
of chronicity. Dissert Abstr Int B Sci Eng 2003;63(9-B):4392.
Zelman DC, Howland EW, Nichols SN, Cleeland CS. The effects of
induced mood on laboratory pain. Pain 1991;46:10511.