Caplanetalibdqol2014 [627805]

ORIGINAL ARTICLE
Attachment, Childhood Abuse, and IBD-related Quality of Life and
Disease Activity Outcomes
Rachel A. Caplan, MA,* Robert G. Maunder, MD,†Joanne M. Stempak, MS,* Mark S. Silverberg, MD, PhD,*,‡
and Tae L. Hart, PhD*,§
Background: This study examined attachment style as a moderator of the relationship between childhood abuse and in flammatory bowel disease
(IBD) –related outcomes.
Methods: Study participants were 205 patients with IBD from Mount Sinai Hospital in Toronto. Participants completed self-report questionnaires
regarding personal relationships, abuse history, and IBD-related information. Multiple regression models were fit using 3 outcome variables: disease-
related quality of life (QOL), disease activity for ulcerative colitis, and disease activity for Crohn ’s disease.
Results: Patients reporting less severe abuse and low levels of avoidant attachment had the highest levels of QOL, whereas patients reporting high levels
of avoidant attachment had the lowest levels of QOL, regardless of abuse severity. Patients reporting greater anxious attachment had lower QOL score s.
Patients reporting less severe abuse and low levels of avoidant attachment had the lowest levels of disease activity, whereas patients reporting hig h levels
of avoidant attachment had the highest levels of ulcerative colitis –related disease activity, regardless of abuse severity. However, for anxious attachment,
there was no signi ficant main effect or signi ficant interaction of abuse by anxious attachment on ulcerative colitis –related disease activity. Childhood
abuse and attachment style were not found to be associated with Crohn ’s disease –related disease activity.
Conclusions: Adult attachment style may moderate the relationship between childhood abuse and IBD-related outcomes, by impacting one ’s QOL and
disease activity. Distinct types of insecure attachment styles may impact these relationships differently. Psychological interventions focusin go n
attachment styles of patients with IBD have the potential to improve IBD-related QOL and disease activity.
(Inflamm Bowel Dis 2014;20:909 –915)
Key Words: inflammatory bowel disease, disease activity, quality of life, attachment, childhood abuse
Crohn’s disease (CD) and ulcerative colitis (UC) are 2 related
gastrointestinal (GI) tract diseases and are referred to more
broadly as in flammatory bowel disease (IBD). Evidence supports
an association between life stress and IBD disease activity.1,2A
history of childhood sexual or physical abuse have both been shown
as important stressful life events that are associated with adverse
coping styles and poor psychological outcomes of individuals with
chronic health conditions, including IBD and other GI disorders.3
Self-reported childhood abuse has been shown repeatedly to
be a predictor of poorer health status among adults.4–6For example,
Wegman et al4conducted a meta-analytic review on 48,801individuals to determine the eff ects of childhood abuse on medical
outcomes in adulthood. They found t hat experiencing childhood abuse
was associated with an increased risk of negative health outcomes in
adulthood, including neurological, m usculoskeletal, respiratory, car-
diovascular, metabolic, and GI prob lems. Importantly, several empir-
ical studies support the idea that childhood abuse is related to worse GI
health status. Leserman et al7found that abused women with GI
disorders were more likely to report symptoms related to panic,
depression, musculoskeletal, gen itourinary, skin disturbance, and
respiratory illnesses. Numerous stud ies have indicated that individuals
with histories of childhood sexual abuse were more likely to report
GI symptomatology,8–10a n dT a l l e ye ta l11found that patients attending
GI clinics were 1.7 times more likely to suffer from irritable bowel
syndrome if they had a history of childhood sexual abuse.
Certain psychological variables may strengthen or attenuate
the relationship between childhood abuse and adult health outcomes.
One important candidate variable is attachment style, de fined as an
interpersonal trait that encompasses the type of bond one had shared
with their caregiver(s) as a result of the caregiver(s) ’levels of sensi-
tivity and responsiveness to their child ’s needs. Attachment style
subsequently leads to the current manner in which one interacts with
romantic partners and is conceptualized as secure or insecure, in the
form of avoidant or anxious –ambivalent attachment.12Insecure
attachment styles have been associated with elevated depressiveReceived for publication January 27, 2014; Accepted January 29, 2014.
From the *Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital,
Joseph and Wolf Lebovic Health Complex, Toronto, Canada;†Department of Psy-
chiatry, and‡Division of Gastroenterology, Mount Sinai Hospital, Toronto, Canada;
and§Department of Psychology, Ryerson University, Toronto, Canada.
This project was partially funded by a CIHR New Investigator Award in
Gender and Health to T. L. Hart.
The authors have no con flicts of interest to disclose.
Reprints: Tae L. Hart, PhD, Department of Psychology, Ryerson University,
350 Victoria Street, Toronto, ON, M5B 2K3, Canada (e-mail: tae.hart@psych.
ryerson.ca).
Copyright © 2014 Crohn ’s & Colitis Foundation of America, Inc.
DOI 10.1097/MIB.0000000000000015
Published online 19 March 2014.
Inflamm Bowel Dis /C15Volume 20, Number 5, May 2014 www.ibdjournal.org |909

symptoms,13,14worse disability,15and have been strongly linked to
impaired biological regulation (such as one ’s stress response)16,17
leading researchers to believe that it may also be related to aspects
of chronic in flammation (such as that found in IBD).
Maunder et al18explored attachment style as a moderating
factor between 2 different adult health outcomes in a sample of
people with UC. They found that the relationship between dis-
ease activity and depression in patients with mild to moderately
severe UC was signi ficantly stronger as the patient ’sl e v e lo f
attachment anxiety increased. Other studies have documented
that insecure attachment styles in addition to childhood abuse
or early childhood trauma independently predict worse physical
health status in samples of physically ill individuals.19,20How-
ever, to our knowledge, the relationships among childhood
abuse, disease activity, and attachment style in those diagnosed
with IBD have yet to be examined. The high costs to the quality
of life (QOL) for patients with IBD, the burden of health care
utilization on society, and the potentially insuf ficient psycholog-
ical care of these patients have created a need to explore, iden-
tify, and target the moderators involved in the relationship
between childhood abuse and IBD-related disease activity.
The purpose of this study was 2-fold: (1) to examine the
relationship between childhood abuse and IBD outcomes (i.e.,
disease activity and IBD-speci fic QOL) and (2) to examine the
extent to which insecure attachment styles moderated the relation-
ship between childhood abuse and IBD outcomes. We hypothe-
sized that childhood abuse would be more likely to be associated
with worse overall disease activity and poor IBD-speci fic QOL,
and that these relationships would be stronger for those with
higher (versus lower) insecure attachment styles.
MATERIALS AND METHODS
Participants and Procedure
After obtaining informed consent, data were collected on 205
participants with IBD who were receiving care at Mount Sinai
Hospital in Toronto, Ontario. Recruitment was conducted in 2 phases.
During the first phase of recruitment, beginning in February 2010,
patients who had previously participated in a study of IBD gene
identi fication and who had agreed to be contacted for future research,
and were residing in Ontario were contacted through a mass mail-out.
We mailed consent forms to 600 potential participants; of these, 149
individuals completed questionnaires. To reach nonresponders, we
had resources to follow up with only 145 patients and found that 27
were either deceased, no longer at the number recorded in the
database, or their number was no longer in service. Therefore, our
final denominator was 573 participants, and the response rate was
26.0% for the first phase. During the second phase of recruitment
(May 2011 –July 2011), participants were approached for study par-
ticipation while waiting to see their g astroenterologist at Mount Sinai
Hospital. During this phase of recruitment, 98 individuals were ap-
proached; of these, 56 patients agr eed to participate and completed
questionnaires, for a response rate of 57.1%. The overall response rate
for both phases of recruitment was 30.6%. Participants completedself-report questionnaires at one poi nt in time either through a secured
online survey software program or through paper questionnaires.
Measurement
Demographic and Medical Information
Study participants provided information on their general
demographic information. In addition, participants self-reported
on their history of hospitalization, medication, and surgery.
Disease Activity
Disease activity of patients with CD was measured using
the Harvey –Bradshaw Index (HBI).21The HBI measures general
well-being (scored 0 –4), abdominal pain (scored 0 –3), number of
liquid stools per day (scored 1 point per stool), abdominal mass
(scored 0 –3), and complications (scored 1 point per complica-
tion). The HBI score indicates that patients with a score of less
than 5 are in remission, 5 to 7 are experiencing mild disease
activity, 8 to 16 are experiencing moderate disease activity, and
more than 16 are experiencing severe disease activity.
Disease activity of patients with UC was measured using
a 6-point scored version of the partial Mayo Scoring System or
“partial Mayo score. ”22Although the partial Mayo score uses
a 9-point scale, which grades frequency of bowel movements,
amount of blood in bowel movements, and physician ’s global
assessment, the 6-point version ( “6-point Mayo score ”) grades fre-
quency of bowel movements (scored 0 –3) and the amount of blood
in bowel movements (scored 0 –3), while excluding physician ’s
global assessment. The 6-point scale, ranging from 0 to 6 has been
found to correlate well with the 9-point partial Mayo score and with
patient assessments of their disease activity.22
Childhood Abuse
Severity of childhood physical and sexual abuse was
measured using the Child Maltreatment History Self-Report.23Par-
ticipants rated their experiences “growing up ”on 2 types of scales;
thefirst was based on whether an event happened; and the second
was based on the frequency of a particular event. Eleven questions
focused on forced sexual contact, threatened sexual contact, and
physical violence (including hitting, attacking, and pushing). Each
item was rated on a 4-point scale ranging from “never ”to“often. ”
Attachment Insecurity
Attachment insecurity (both att achment anxiety and attachment
avoidance) was measured using the widely-used Experiences in Close
Relationships-Revised (ECR-R) questionnaire.24This 36-item ques-
tionnaire assesses how one generally feels in emotionally close rela-
tionships by asking participants to rate each statement on a 7-point
Likert scale ranging from “strongly disagree ”to“strongly agree. ”
Disease-speci fic QOL
Participant QOL was measured using the In flammatory Bowel
Disease Questionnaire (IBDQ), which assesses health-related QOL in
patients with IBD.25Gick and Sirois26confirmed that self-report indi-
ces such as the IBDQ have been shown frequently in research liter-
ature to correlate with various phys ician-based measures of diseaseCaplan et al Inflamm Bowel Dis /C15Volume 20, Number 5, May 2014
910 |www.ibdjournal.org

activity. This 32-item questionnaire assesses 4 domains, including GI
symptoms, systemic symptoms, emotional function, and social func-
tion. It also includes assessments of physical symptoms, such as
abdominal pain, cramping, diarrhea, and psychological symptoms,
such as fatigue, depressed mood, worry, and social avoidance. Each
question was rated based on either severity (e.g., of pain) or frequency
(e.g., of physical or psychological symptom presence) on a 7-point
Likert scale ranging from 0 (none of the time) to 6 (all of the time).
Social Support
Social support was measured using the UCLA Social
Support Inventory.27This self-administered, 12-item measure as-
sesses the extent to which participants received varying types of
support such as information and advice, aid and assistance, and
emotional support on a 5-point Likert scale ranging from 0 (never
or very dissatis fied) to 4 (very often or very satis fied).
Data Analyses
Wefit multiple regression models , using 3 outcome variables:
(1) disease-related QOL (using the IBDQ), (2) UC-speci ficd i s e a s e
activity (using the 6-point Mayo score), and (3) Crohn ’s-speci fic
disease activity (using the HBI). The following variables were
entered into each model: (1) covariates: age of IBD onset, recruit-
ment phase, and social support, (2) abuse severity, (3) attachment
style (avoidant or anxious), which were tested separately for each of
the 3 outcomes, (4) abuse severity X attachment style interaction
term. All analyses were performed with IBM SPSS Statistics 20.0.28
Ethical Considerations
The study was reviewed and approved by the Research
Ethics Board for both Mount Sinai Hospital and RyersonUniversity in Toronto, Ontario. Individually identi fiable data
were removed to ensure privacy for all participants.
RESULTS
Sample Characteristics
Table 1 displays the demographic data and clinical charac-
teristics of the sample. Of the 205 participants, 12 had incomplete
data on many of the demographic and medical variables and
therefore, were not analyzed. For the sample of 193 participants
included in analyses, approximately half were male (54.4%), and
62.7% were diagnosed with UC, whereas the other 37.3% were
diagnosed with CD. The overall mean age was 46.3 years and the
majority of participants were white (87.8%). Unwanted sexual
contact was infrequently reported in the sample (10.6%) but the
majority of participants (80.0%) did report some type of physical
violence in flicted by adults during their childhood.
A substantial minority of participants had experienced an
IBD-related flare in the last year and/or at the time of survey
completion. Among those with CD, the majority (57.6%) had
a prior surgical resection, and the mean HBI score was 6.61.
Among those with UC, 7.7% had a prior surgical resection, and
the mean 6-point Mayo score was 0.58. Table 1 also shows the
mean scores and SDs for the psychological and QOL measures
completed by participants.
Because recruitment was conducted in 2 phases and used
different methods of recruitment (mai l-based recruitment versus clinic-
based recruitment), we statistically compared phase 1 (N ¼149)
versus phase 2 (N ¼56) participants. Phase 2 (versus phase 1) par-
ticipants were signi ficantly more likely to (1) have been diagnosed
TABLE 1. Demographic Data and Clinical Characteristics of the Sample (N ¼193)
Characteristic CD (36.1%) UC (62.7%) Total Sample (n ¼193)
Male gender, % 51.4 56.2 54.4
Age, mean, yr (SD) 41.5 (14.4) 49.2 (13.5) 46.3 (14.2)
Age, range, yr 18 –76 23 –78 18 –78
Age of onset, mean, yr (SD) 25.14 (SD) 29.07 (SD) 27.11 (SD)
White ethnicity, % 88.6 87.4 87.8
Flare (past year since survey), % 49.3 37.4 42.0
Flare (at time of survey), % 30.6 16.5 22.6
Surgical resection, % 57.6 7.7 25.8
Disease activity measures, mean (SD) —— —
HBI 6.61 (4.37) ——
6-point Mayo score — 0.58 (0.95) —
Psychological and lifestyle measures —— —
Inflammatory Bowel Disease Questionnaire, total 5.50 (3.13) 5.82 (2.96) 5.74 (3.02)
UCLA total score 23.8 (5.13) 22.1 (5.43) 22.8 (5.42)
Experiences in close relationships (anxious attachment) 1.76 (1.23) 1.74 (1.20) 1.75 (1.20)
Experiences in close relationships (avoidant attachment) 2.96 (0.46) 2.92 (0.48) 2.92 (0.47)
Childhood maltreatment self report 2.19 (2.99) 3.08 (3.46) 2.90 (3.49)Inflamm Bowel Dis /C15Volume 20, Number 5, May 2014 Attachment, Abuse, and IBD-related QOL and Disease Activity Outcomes
www.ibdjournal.org |911

with CD (66.7% versus 25.9%; P,0.001), (2) be younger (mean ¼
37.1 versus 50.1 yr; P,0.001), (3) have an earlier age of IBD onset
(mean ¼2 4 . 2v e r s u s2 8 . 8y r ; P¼0.005), (4) have worse IBDQ
scores (mean ¼6.7 versus 5.4 yr; P¼0.017) and for the subset of
patients diagnosed with UC, (5) have worse 6-point Mayo scores
(mean ¼1.07 versus 0.49 yr; P¼0.035). Therefore, phase of recruit-
ment was used as a covariate in all analyses.
Abuse Severity, Insecure Attachment, and QOL
Table 2 displays the estimates, SEs and signi ficance levels
for regression analyses using the IBDQ as the outcome variable
with the following predictor variables: age, recruitment phase,
type of IBD (CD versus UC), social support, childhood abuse
severity, avoidant attachment, and the interaction of abuse sever-
ity X avoidant attachment (Model 1). The overall regression
model was statistically signi ficant, F ¼5.64, adjusted R2¼
0.23, P,0.001. After controlling for age, recruitment phase,
and social support, the only signi ficant predictor was the interac-
tion term of abuse severity X avoidant attachment (b ¼0.24, P¼
0.016). Figure 1 displays the signi ficant interaction effect, in
which both severity of abuse and avoidant attachment were
divided into high and low levels through a median split and
plotted against one another. As shown, patients who reported
low-abuse severity and low-avoidant attachment reported the
highest levels of QOL. This stands in contrast to patients who
reported high levels of avoidant attachment and reported the low-
est QOL scores, regardless of abuse severity. In addition, using
the same analytic model, but examining the effect of anxious
attachment and the interaction of abuse severity X anxious attach-
ment (Model 2) produced similar findings. Table 2 shows thatafter controlling for age, recruitment phase, and social support,
greater anxious attachment (b ¼0.29, P¼0.002) was signi fi-
cantly associated with worse QOL. Moreover, the interaction of
abuse severity X anxious attachment (b ¼0.19, P¼0.051)
showed a nonsigni ficant trend toward worse QOL, such that
patients reporting higher levels of abuse and more severe anxious
attachment had the lowest QOL scores, compared with those with
lower levels of abuse and less anxious attachment (data not shown
because of statistically nonsigni ficantfindings).
Abuse Severity, Insecure Attachment, and CD
Disease Activity
The overall regression model was not statistically signi fi-
cant using the HBI for CD disease activity as the outcome variable
and predictor variables of age, recruitment phase, social support,
abuse severity, avoidant attachment, and the interaction of abuse
severity X avoidant attachment (F ¼1.6, adjusted R2¼0.08, P¼
0.18). The only statistically signi ficant variable associated with
higher HBI scores was more severe abuse (b ¼0.39 P¼0.026).
A similar pattern of findings emerged for anxious attachment and
the interaction of abuse severity X anxious attachment, using the
same analytic model described above. The overall regression
model was not statistically signi ficant (F ¼1.29, adjusted R2¼
0.04, P¼0.28), and none of the variables included in the model
were signi ficantly associated with HBI scores.
Abuse Severity, Insecure Attachment, and UC
Disease Activity
Table 3 displays the estimates, SEs, and signi ficance levels
for regression analyses, using the 6-point Mayo score as the out-
come variable and the following predictor variables: age, recruit-
ment phase, social support, abuse severity, avoidant attachment,
and the interaction of abuse severity X avoidant attachment. The
overall regression model was statistically signi ficant (F ¼4.5,
adjusted R2¼0.26, P,0.001). Only the interaction of abuse
severity X avoidant attachment (b ¼20.33, P¼0.011) was
significantly associated with worse UC-related disease activity.
Figure 2 displays the signi ficant interaction effect, in which bothTABLE 2. Results of Multiple Regression Analyses
Predicting In flammatory Bowel Disease Questionnaire
Scores
Parameter Estimate SE t P
Model 1: avoidant attachment
Age at IBD onset 20.08 0.03 20.92 0.359
Recruitment phase 0.38 0.73 3.81 0.001
Type of IBD (CD versus UC) 0.07 0.59 0.75 0.453
Social support 20.24 0.06 22.41 0.018
Abuse severity 0.12 0.09 1.16 0.248
Avoidant attachment 0.07 0.58 0.73 0.465
Abuse severity X avoidant attachment 0.24 0.17 2.46 0.016
Model 2: anxious attachment
Age at IBD onset 20.08 0.02 20.94 0.351
Recruitment phase 0.32 0.70 3.34 0.001
Type of IBD (CD versus UC) 0.05 0.56 0.65 0.518
Social support 20.10 0.06 21.04 0.303
Abuse severity 0.11 0.09 1.07 0.286
Anxious attachment 0.29 0.24 3.20 0.002
Abuse severity X anxious attachment 0.19 0.20 1.97 0.051
FIGURE 1. Interaction of abuse severity by avoidant attachment in the
prediction of in flammatory bowel disease questionnaire (IBDQ) scores.Caplan et al Inflamm Bowel Dis /C15Volume 20, Number 5, May 2014
912 |www.ibdjournal.org

severity of abuse and avoidant attachment were divided into
high and low levels through a median split and plotted against
one another. As shown, patients who reported low-abuse
severity and low-avoidant attach ment reported the lowest lev-
els of disease activity. This stands in contrast to patients who
reported high levels of avoidant attachment and reported the
highest level of UC-related disease activity, regardless of
abuse severity.
However, a regression using the same analytic model, but
examining the effect of anxious attachment and the interaction of
abuse severity X anxious attachment did not produce similar
findings (Table 3, Model 2). Although the overall model was
statistically signi ficant (F ¼3.0, adjusted R2¼0.17, P¼
0.012) after controlling for age, recruitment phase, and social
support, the only psychological predictor signi ficantly associated
with better UC-related disease activity was more social support
(b¼0.33, P¼0.029).DISCUSSION
Many studies have documented an association between IBD
type and/or activity with psychological functioning and QOL.29–34
Furthermore, other studies have de monstrated associations between
childhood abuse with IBD-related QOL or poor gastroenterological
health conditions.5,35–40Additionally, numerous studies have dem-
onstrated the importance of attachment style in patients with phys-
ical and/or psychological health conditions.13–20
This study adds to this literature in its evaluation of the
relationship between childhood abuse and IBD-related disease activity
and QOL. In addition, insecure attachment styles were examined to
determine whether they moderated the relationship between child-
hood abuse and IBD-related outcomes. The findings indicated that
insecure attachment (anxious or avoidant) was associated with worse
IBD-related QOL. We had expected that patients with more severe
abuse and greater avoidant attachment would report the worst QOL.
However, our data showed that the moderation effect occurred for
patients with less severe abuse and less avoidant attachment, such that
this group reported the highest level of QOL compared with all other
patients. Findings also indicated that although childhood abuse was
associated with disease activity in patients with UC, the relationship
was only signi ficant when moderated by an avoidant attachment style,
but not by an anxious attachment style. Furthermore, childhood abuse
was not signi ficantly associated with disease activity in patients with
CD, even when insecure attachment styles were included into the
model as potential moderators.
Multiple studies have suggested the moderating role of
attachment between IBD activity and psychobiological varia-
bles.18,41,42Ample data suggest that avoidantly attached individuals
tend to be more self-reliant and less likely to seek external supports
than those who are anxiously attached.26,42 –44Moreover, Kotler
et al45have suggested that avoidant coping styles serve to amplify
distress and vulnerability to physical and psychological illness.
Similarly, increased disease activity in patients with IBD has been
associated consistently with avoidant coping styles.46It is possible
that for these reasons, patients with anxious attachment sought
treatment for their IBD, whereas patients with avoidant attachments
and coping styles avoided seeking treatment for their IBD, which
led to worse disease activity. Although our study cannot show this
causal link, future research might examine this possibility.
We predicted that more severe childhood abuse would be
associated with worse QOL and overall disease activity for patients
with both CD and UC with an even st ronger relationship for those
with higher insecure attachment sty les. This prediction was based on
studies showing that bot h insecure attachment styles and childhood
abuse or early traumatic events independently predict worse
physical health status in sample s of physically ill individuals.19,20
Instead, our findings indicated that lower levels of both abuse and
avoidant attachment ha d a protective effect for QOL and UC disease
activity. For patients with IBD whom are high in avoidant attach-
ment, why did severity of child hood abuse not seem to matter?
Other studies showing that both insecure attachment styles
and childhood abuse (or traumatic events) independently predictTABLE 3. Results of Multiple Regression Analyses
Predicting 6-Point Mayo Scores
Parameter Estimate SE t P
Model 1: avoidant attachment
Age at IBD onset 0.05 0.01 0.38 0.709
Recruitment phase 0.22 0.32 1.81 0.077
Social support 0.24 0.03 1.85 0.071
Abuse severity 0.16 0.04 1.24 0.222
Avoidant attachment 0.24 0.29 1.95 0.056
Abuse severity X avoidant attachment 20.33 0.21 22.65 0.011
Model 2: anxious attachment
Age at IBD onset 20.01 0.01 20.06 0.950
Recruitment phase 0.29 0.35 2.21 0.032
Social support 0.33 0.03 2.25 0.029
Abuse severity 0.25 0.04 1.95 0.057
Avoidant attachment 0.12 0.13 0.87 0.389
Abuse severity X avoidant attachment 0.13 0.17 1.05 0.298
FIGURE 2. Interaction of abuse severity by avoidant attachment in the
prediction of 6-point Mayo scores.Inflamm Bowel Dis /C15Volume 20, Number 5, May 2014 Attachment, Abuse, and IBD-related QOL and Disease Activity Outcomes
www.ibdjournal.org |913

worse physical health status19,20differ from this study in some
important methodological ways. For example, one study recruited
community samples with very high rates of sexual abuse and high
rates of current physical abuse by an intimate partner,20and the
other study used much broader measurements of early childhood
trauma in a community sample of obese and nonobese patients, of
which sexual and physical abuse were 1 of 10 types of traumatic
events.19Therefore, it is possible that our sample was less trau-
matized compared with previous studies. Importantly, neither of
those studies examined patients from a clinic setting who were
diagnosed with an ongoing chronic illness, such as IBD. Attach-
ment style is considered to be a “working schema ”through which
the patient processes their world and that is even more activated
under conditions of threat.47For patients with IBD, a disease for
which there is no cure, but only treatment available, avoidant
attachment style seems to be the more relevant predictor of both
lower QOL and worse disease activity.
Contrary to our expectations, the interaction of childhood
abuse and avoidant attachment was not signi ficantly associated with
disease activity in patients with CD, but it was in patients with UC.
Although CD and UC share many similar clinical symptoms, CD is
often a more complicated and severe condition.32,48Often attributed
to the increased severity and complexity of CD, multiple studies
have found differences between psychological distress when related
to disease type and activity in patients with IBD. For example,
higher psychological distress has been found in patients with CD
than those with UC.34,49Other researchers have found that patients
with CD tend to have a poorer health-related QOL than those with
UC.50–52Lix et al31found CD to be associated with more pain,
higher health care utilization, and more dif ficulty stabilizing pain.
According to these findings, there seems to be a difference between
the psychological experiences of patients with CD and those with
UC. Conversely, other studies have failed to find differences
between psychological distress when related to disease type and
activity in patients with IBD. For example, Guthrie et al30found
no differential mood-based effects between patients with CD and
UC. Because of the complex nature of CD, psychological moder-
ators in addition to attachment style may be necessary to uncover
a potential relationship between childhood abuse and CD disease
activity. Furthermore, because of the small number of patients diag-
nosed with CD recruited for this study, low power to detect signif-
icant findings prevent us from drawing firm conclusions about the
lack of a signi ficant relationship among childhood abuse, attach-
ment, and disease activity.
The methods of this study present some limitations. As
noted, low power may have prevented detection of signi ficant
findings among those diagnosed with CD. Second, because of the
correlational design, causality or directionality of the findings
cannot be determined. However, because attachment styles can be
modified through psychotherapy, future studies may potentially
determine causal relationships between insecure attachment and
IBD-related outcomes. Finally, a major limitation of our study was
the poor overall response rate of 30.6%. However, when disag-
gregating the 2 phases of recruitment, it is clear that face-to-facerecruitment in the second phase resulted in a substantially higher
response rate (57.1%), than mail-out recruitment in the first phase
(26.0%). This might be for a variety of reasons, including the fact
that patients contacted through mail-out had been in the database
for over 10 years, and therefore, may have moved, aged, or become
deceased since their address information was initially collected.
In summary, avoidant attachment style was found to
moderate the statistical relationship between childhood abuse and
Q O Li np a t i e n t sw i t hb o t hC Da n dU C ,a sw e l la sb e t w e e n
childhood abuse and disease activity in patients with UC. These
findings may have clinical usefulness and implications for psycho-
logical treatment of patients with IBD. Multiple studies have
demonstrated the bene fits of psychological treatments and supports
for patients with IBD.30,32,53 –55Leserman39described the bene fits of
emotional expressive writing and cognitive behavioral treatments in
reducing pain and disability in patients with chronic pain disorders,
and Larsson et al32suggested that counselors, such as medical social
workers be integrated into routine gastroenterological care.
Waldinger et al20suggested that physicians screen patients for
attachment style to implement a more patient-centered approach
to treatment and support, and Maunder and Hunter41explained
how attachment theory could be useful in developing psychological
treatment approaches for patients with medical illnesses. It is sug-
gested, that as part of standard practice, gastroenterologists should
obtain relationship information regarding attachment styles from
their patients, to help identify potential patients requiring immediate
psychological and/or behavioral interventions, which may result in
better QOL and disease course overall.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the contributions of the
following individuals: Lori Caplan, Joseph Donia, Sabrina Lalji,
Maayan Marcus, Aliza Panjwani, Reena Rosenwald, Lindsey
Torbit, Karen Zhang, and all of the research participants who gave
their time.
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