Attachment and Emotion Regulation among Adults with versus without Somatic Symptom Disorder
This cross-sectional study aims to explore the differences among adults with somatic symptom disorder (SSD) versus adults without SSD, in terms of attachment and emotion regulation strategies. A total sample of 80 participants (40 people with SSD and 40 healthy controls), aged 20-57 years old (M = 31.69, SD = 10.55), were recruited from institutions and online groups. They completed the Romanian version of the Experiences in Close Relationships Scale – Short Form (ECR-S), Regulation of Emotion Systems Survey (RESS), Patient Health Questionnaire-15 (PHQ-15) and Somatic Symptom Disorder – B Criteria Scale (SSD-12). The results indicate significant differences between the two groups in terms of attachment and emotion regulation strategies. Adults with SSD have a higher level of attachment anxiety and avoidance compared to the nonclinical group. Moreover, people with SSD are more prone to use rumination and suppression and less prone to use reevaluation compared to healthy people. Implications for SSD prevention and treatment are discussed.
[1] P. R. Muskin, “Psychosomatic medicine,” The American Journal of Psychiatry, vol. 165, no. 1, pp. 141–142, 2008.
[2] Z. J. Lipowski, “Somatization: the concept and its clinical application,” American Journal of Psychiatry, vol. 145, no. 11, pp. 1358–1368, 1988.
[3] R. J. Brown, “Introduction to the special issue on medically unexplained symptoms: background and future directions,” Clinical Psychology Review, vol. 27, no. 7, pp. 769–780, 2007.
[4] O. Van den Bergh, M. Witthöft, S. Petersen, and R. J. Brown, “Symptoms and the body: taking the inferential leap,” Neuroscience and Biobehavioral Reviews, vol. 74, pp. 185–203, 2017.
[5] American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 4th Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000 (Asociația Pishiatrilor Liberi din România, Manual de Diagnostic și Statistică a tulburărilor mentale, ediția a IV-a revizuită, DSM IV-TR. București: Editura Pegasus, 2003, pp. 485–517).
[6] American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 5th Edition (DSM-V), 2013 (DSM-5: Manual de diagnostic și clasificare statistică a tulburărilor mintale. București: Editura Medicală Callisto, 2016, pp. 309–327).
[7] A. D. Statt, The concise dictionary of psychology. London and New York: Routledge, 2003.
[8] J. Bowlby, Attachment and Loss: Vol. 2. Separation: anxiety and anger. New York: Basic Books, 1973.
[9] J. Bowlby, Attachment and Loss: Vol. 3. Loss: sadness and depression. New York: Basic Books, 1980.
[10] A. Agostini, F. Rizzello, G. Ravegnani, P. Gionchetti, R. Tambasco, M. Ercolani, and M. Campieri, “Parental bonding and inflammatory bowel disease,” Psychosomatics, vol. 51, no. 1, pp. 14–21, 2010.
[11] M. Shibata, T. Ninomiya, K. Anno, H. Kawata, R. Iwaki, R. Sawamoto, C. Kubo, Y. Kiyohara, N. Sudo, and M. Hosoi, “Perceived inadequate care and excessive overprotection during childhood are associated with greater risk of sleep disturbance in adulthood: the Hisayama Study,” BMC Psychiatry, vol. 16, 1–10, 2016.
[12] Y. Nacak, E. Morawa, D. Tuffner, and Y. Ermin, “Insecure attachment style and cumulative traumatic life events in patients with somatoform pain disorder: A cross-sectional study,” Journal of Psychosomatic Research, vol. 103, pp. 77–82, 2017.
[13] E. Waller, C. E. Scheidt, and A. Hartmann, “Attachment representation and illness behavior in somatoform disorders,” The Journal of Nervous and Mental Disease, vol. 192, no. 3, pp. 200–209, 2004.
[14] K. A. Davies, G. J. Macfarlane, J. McBeth, R. Morriss, and C. Dickens, “Insecure attachment style is associated with chronic widespread pain,” Pain, vol. 143, no. 3, pp. 200–205, 2009.
[15] L. A. McWilliams and S. J. Bailey, “Associations between adult attachment ratings and health conditions: evidence from the National Comorbidity Survey Replication,” Health Psychology, vol. 29, no. 4, pp. 446–453, 2010.
[16] N. Eisenberg and T. L. Spinrad, “Emotion-related regulation: sharpening the Definition,” Child Development, vol. 75, no. 2, pp. 334–339, 2004.
[17] K. L. Gratz and L. Roemer, “Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale,” Journal of Psychopathology and Behavioral Assessment, vol. 26, no. 1, pp. 41–54, 2004.
[18] J. J. Gross and R. A. Thompson, “Emotion regulation: conceptual foundations,” in Handbook of emotion regulation, J. J. Gross, Ed. New York: Guilford Press, 2007, pp. 3–24.
[19] Y. Song, H. Lu, S. Hu, M. Xu, X. Li, and J. Liu, “Regulating emotion to improve physical health through the amygdala,” Social cognitive and affective neuroscience, vol. 10, no. 4, pp. 523–530, 2015.
[20] M. Lilly and C. Valdez, “The unique relationship of emotion regulation and alexithymia in predicting somatization versus PTSD symptoms,” Journal of Aggression, Maltreatment & Trauma, vol. 21, no. 6, pp. 609–625, 2012.
[21] M. Mazaheri, “Difficulties in emotion regulation and mindfulness in psychological and somatic symptoms of functional gastrointestinal disorders,” Iranian Journal of Psychiatry and Behavioral Sciences, vol. 9, no. 4, e954, 2015.
[22] E. Waller and C. E. Scheidt, “Somatoform disorders as disorders of affect regulation: A development perspective,” International Review of Psychiatry, vol. 18, no. 1, pp. 13–24, 2006.
[23] M. Erkic, J. Bailer, S. C. Fenske, S. N. L. Schmidt, J. Trojan, A. Schröder, P. Kirsch, and D. Mier, “Impaired emotion processing and a reduction in trust in patients with somatic symptom disorder,” Clinical Psychology & Psychotherapy, vol. 25, no. 1, pp. 163–172, 2018.
[24] Z. E. Okur Güney, H. Sattel, M. Witthöft, and P. Henningsen, “Emotion regulation in patients with somatic symptom and related disorders: A systematic review,” PLoS One, vol. 14, no. 6, e0217277, 2019.
[25] O. Pollatos, B. M. Herbert, S. Wankner, A. Dietel, C. Wachsmuth, P. Henningsen, and M. Sack, “Autonomic imbalance is associated with reduced facial recognition in somatoform disorders,” Journal of Psychosomatic Research, vol. 71, no. 4, 232–239, 2011.
[26] C. Subic-Wrana, M. E. Beutel, A. Knebel, and R. D. Lane, “Theory of mind and emotional awareness deficits in patients with somatoform disorder,” Psychosomatic Medicine, vol. 72, no. 4, pp. 404–411, 2010.
[27] M. Bahremand, M. Alikhani, A. Zakiei, P. Janjani, and A. Aghei, “Emotion risk-factor in patients with cardiac diseases: the role of cognitive emotion regulation strategies, positive affect and negative affect (a case-control study),” Global journal of health science, vol. 8, no. 1, pp. 173–179, 2016.
[28] F. Sheybani Noghabi, A. Ashgharnejad, F. Fathali Lavasani, and A. Noorbala, “Comparison of emotion regulation dimensions and attachment styles between people with somatization disorder and normal individuals,” Hormozgan Medical Journal, vol. 19, no. 4, pp. 245–251, 2015.
[29] M. Walentynowicz, F. Raes, I. Van Diest, and O. Van den Bergh, “The specificity of health-related autobiographical memories in patients with somatic symptom disorder,” Psychosomatic medicine, vol. 79, no. 1, pp. 43–49, 2017.
[30] P. Hüsing, B. Löwe, T. C. Olde Hartman, L. Frostholm, and A. Weigel, “Helpful explanatory models for somatoform symptoms (HERMES): study protocol of a randomized mixed-methods pilot trial,” BMJ Open, vol. 11, no.3, e044244, 2021.
[31] S.-C. Liao, W.-L. Huang, H.-M. Ma, M.-T. Lee, T.-T. Chen, I.-M. Chen, and S. S.-F. Gau, “The relation between the patient health questionnaire-15 and DSM somatic diagnoses,” BMC Psychiatry, vol. 16, no. 1, e351, 2016.
[32] A. Touusaint, B. Löwe, E. Brähler, and P. Jordan, “The Somatic Symptom Disorder - B Criteria Scale (SSD-12): factorial structure, validity and population-based norms,” Journal of psychosomatic research, vol. 97, pp. 9–17, 2017.
[33] A. Toussaint, P. Hüsing, S. Kohlmann, and B. Löwe, “Detecting DSM-5 somatic symptom disorder: criterion validity of the Patient Health Questionnaire-15 (PHQ-15) and the Somatic Symptom Scale-8 (SSS-8) in combination with the Somatic Symptom Disorder - B Criteria Scale (SSD-12),” Psychological medicine, vol. 50, no. 2, pp. 324–333, 2020.
[34] K. Kroenke, R. L. Spitzer, and J. B. Williams, “The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms,” Psychosomatic medicine, vol. 64, no. 2, pp. 258–266, 2002.
[35] A. Toussaint, A. M. Murray, K. Voigt, A. Herzog, B. Gierk, K. Kroenke, W. Rief, P. Henningsen, and B. Löwe, “Development and validation of the Somatic Symptom Disorder-B Criteria Scale (SSD-12),” Psychosomatic medicine, vol. 78, no. 1, pp. 5–12, 2016.
[36] M. Wei, D. W. Russell, B. Mallinckrodt, and D. L. Vogel, “The Experiences in Close Relationship Scale (ECR)-short form: reliability, validity, and factor structure,” Journal of Personality Assessment, vo. 88, no. 2, pp. 187–204, 2007.
[37] K. A. Brennan, C. L. Clark, and P. R. Shaver, “Self-report measurement of adult attachment: an integrative overview,” in Attachment theory and close relationships, J. A. Simpson and W. S. Rholes, Eds. New York: Guilford Press, 1998, pp. 46–76.
[38] K. De France and T. Hollenstein, “Assessing emotion regulation repertoires: the Regulation of Emotion Systems Survey,” Personality and Individual Differences, vol. 119, pp. 204–215, 2017.
[39] Pfizer, accessed June 2021, <https://www.phqscreeners.com>.
[40] R.-D. Kocalevent, A. Hinz, and E. Brähler, “Standardization of a screening instrument (PHQ-15) for somatization syndromes in the general population,” BMC Psychiatry, vol. 13, e91, 2013.
[41] The jamovi project, version 1.8 (Computer Software), retrieved from https://www.jamovi.org, 2021.
[42] R. C. Fraley, University of Illinois at Urbana-Champaign, 2012, accessed June 2021, <http://labs.psychology.illinois.edu/~rcfraley/measures/ecrr. htm>.
[43] S. S. Shapiro and M. B. Wilk, “An analysis of variance test for normality (complete samples),” Biometrika, vol. 52, no. 3–4, 1965, pp. 591–611.
[44] C. Croicu, L. Chwastiak, and W. Katon, “Approach to the patient with multiple somatic symptoms,” The Medical Clinics of North America, vol. 98, no. 5, pp. 1079–1095, 2014.
[45] A. Landa, M. Makous, and B. A. Fallon, “Treating somatic symptom disorder and illness anxiety in integrated care setting,” in Integrating Behavioral Health and Primary Care, R. Feinsstein, J. Connely, and M. Feinstein, Eds. Oxford: Oxford University Press, 2017, pp. 276–302.
[1] P. R. Muskin, “Psychosomatic medicine,” The American Journal of Psychiatry, vol. 165, no. 1, pp. 141–142, 2008.
[2] Z. J. Lipowski, “Somatization: the concept and its clinical application,” American Journal of Psychiatry, vol. 145, no. 11, pp. 1358–1368, 1988.
[3] R. J. Brown, “Introduction to the special issue on medically unexplained symptoms: background and future directions,” Clinical Psychology Review, vol. 27, no. 7, pp. 769–780, 2007.
[4] O. Van den Bergh, M. Witthöft, S. Petersen, and R. J. Brown, “Symptoms and the body: taking the inferential leap,” Neuroscience and Biobehavioral Reviews, vol. 74, pp. 185–203, 2017.
[5] American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 4th Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000 (Asociația Pishiatrilor Liberi din România, Manual de Diagnostic și Statistică a tulburărilor mentale, ediția a IV-a revizuită, DSM IV-TR. București: Editura Pegasus, 2003, pp. 485–517).
[6] American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 5th Edition (DSM-V), 2013 (DSM-5: Manual de diagnostic și clasificare statistică a tulburărilor mintale. București: Editura Medicală Callisto, 2016, pp. 309–327).
[7] A. D. Statt, The concise dictionary of psychology. London and New York: Routledge, 2003.
[8] J. Bowlby, Attachment and Loss: Vol. 2. Separation: anxiety and anger. New York: Basic Books, 1973.
[9] J. Bowlby, Attachment and Loss: Vol. 3. Loss: sadness and depression. New York: Basic Books, 1980.
[10] A. Agostini, F. Rizzello, G. Ravegnani, P. Gionchetti, R. Tambasco, M. Ercolani, and M. Campieri, “Parental bonding and inflammatory bowel disease,” Psychosomatics, vol. 51, no. 1, pp. 14–21, 2010.
[11] M. Shibata, T. Ninomiya, K. Anno, H. Kawata, R. Iwaki, R. Sawamoto, C. Kubo, Y. Kiyohara, N. Sudo, and M. Hosoi, “Perceived inadequate care and excessive overprotection during childhood are associated with greater risk of sleep disturbance in adulthood: the Hisayama Study,” BMC Psychiatry, vol. 16, 1–10, 2016.
[12] Y. Nacak, E. Morawa, D. Tuffner, and Y. Ermin, “Insecure attachment style and cumulative traumatic life events in patients with somatoform pain disorder: A cross-sectional study,” Journal of Psychosomatic Research, vol. 103, pp. 77–82, 2017.
[13] E. Waller, C. E. Scheidt, and A. Hartmann, “Attachment representation and illness behavior in somatoform disorders,” The Journal of Nervous and Mental Disease, vol. 192, no. 3, pp. 200–209, 2004.
[14] K. A. Davies, G. J. Macfarlane, J. McBeth, R. Morriss, and C. Dickens, “Insecure attachment style is associated with chronic widespread pain,” Pain, vol. 143, no. 3, pp. 200–205, 2009.
[15] L. A. McWilliams and S. J. Bailey, “Associations between adult attachment ratings and health conditions: evidence from the National Comorbidity Survey Replication,” Health Psychology, vol. 29, no. 4, pp. 446–453, 2010.
[16] N. Eisenberg and T. L. Spinrad, “Emotion-related regulation: sharpening the Definition,” Child Development, vol. 75, no. 2, pp. 334–339, 2004.
[17] K. L. Gratz and L. Roemer, “Multidimensional assessment of emotion regulation and dysregulation: development, factor structure, and initial validation of the difficulties in emotion regulation scale,” Journal of Psychopathology and Behavioral Assessment, vol. 26, no. 1, pp. 41–54, 2004.
[18] J. J. Gross and R. A. Thompson, “Emotion regulation: conceptual foundations,” in Handbook of emotion regulation, J. J. Gross, Ed. New York: Guilford Press, 2007, pp. 3–24.
[19] Y. Song, H. Lu, S. Hu, M. Xu, X. Li, and J. Liu, “Regulating emotion to improve physical health through the amygdala,” Social cognitive and affective neuroscience, vol. 10, no. 4, pp. 523–530, 2015.
[20] M. Lilly and C. Valdez, “The unique relationship of emotion regulation and alexithymia in predicting somatization versus PTSD symptoms,” Journal of Aggression, Maltreatment & Trauma, vol. 21, no. 6, pp. 609–625, 2012.
[21] M. Mazaheri, “Difficulties in emotion regulation and mindfulness in psychological and somatic symptoms of functional gastrointestinal disorders,” Iranian Journal of Psychiatry and Behavioral Sciences, vol. 9, no. 4, e954, 2015.
[22] E. Waller and C. E. Scheidt, “Somatoform disorders as disorders of affect regulation: A development perspective,” International Review of Psychiatry, vol. 18, no. 1, pp. 13–24, 2006.
[23] M. Erkic, J. Bailer, S. C. Fenske, S. N. L. Schmidt, J. Trojan, A. Schröder, P. Kirsch, and D. Mier, “Impaired emotion processing and a reduction in trust in patients with somatic symptom disorder,” Clinical Psychology & Psychotherapy, vol. 25, no. 1, pp. 163–172, 2018.
[24] Z. E. Okur Güney, H. Sattel, M. Witthöft, and P. Henningsen, “Emotion regulation in patients with somatic symptom and related disorders: A systematic review,” PLoS One, vol. 14, no. 6, e0217277, 2019.
[25] O. Pollatos, B. M. Herbert, S. Wankner, A. Dietel, C. Wachsmuth, P. Henningsen, and M. Sack, “Autonomic imbalance is associated with reduced facial recognition in somatoform disorders,” Journal of Psychosomatic Research, vol. 71, no. 4, 232–239, 2011.
[26] C. Subic-Wrana, M. E. Beutel, A. Knebel, and R. D. Lane, “Theory of mind and emotional awareness deficits in patients with somatoform disorder,” Psychosomatic Medicine, vol. 72, no. 4, pp. 404–411, 2010.
[27] M. Bahremand, M. Alikhani, A. Zakiei, P. Janjani, and A. Aghei, “Emotion risk-factor in patients with cardiac diseases: the role of cognitive emotion regulation strategies, positive affect and negative affect (a case-control study),” Global journal of health science, vol. 8, no. 1, pp. 173–179, 2016.
[28] F. Sheybani Noghabi, A. Ashgharnejad, F. Fathali Lavasani, and A. Noorbala, “Comparison of emotion regulation dimensions and attachment styles between people with somatization disorder and normal individuals,” Hormozgan Medical Journal, vol. 19, no. 4, pp. 245–251, 2015.
[29] M. Walentynowicz, F. Raes, I. Van Diest, and O. Van den Bergh, “The specificity of health-related autobiographical memories in patients with somatic symptom disorder,” Psychosomatic medicine, vol. 79, no. 1, pp. 43–49, 2017.
[30] P. Hüsing, B. Löwe, T. C. Olde Hartman, L. Frostholm, and A. Weigel, “Helpful explanatory models for somatoform symptoms (HERMES): study protocol of a randomized mixed-methods pilot trial,” BMJ Open, vol. 11, no.3, e044244, 2021.
[31] S.-C. Liao, W.-L. Huang, H.-M. Ma, M.-T. Lee, T.-T. Chen, I.-M. Chen, and S. S.-F. Gau, “The relation between the patient health questionnaire-15 and DSM somatic diagnoses,” BMC Psychiatry, vol. 16, no. 1, e351, 2016.
[32] A. Touusaint, B. Löwe, E. Brähler, and P. Jordan, “The Somatic Symptom Disorder - B Criteria Scale (SSD-12): factorial structure, validity and population-based norms,” Journal of psychosomatic research, vol. 97, pp. 9–17, 2017.
[33] A. Toussaint, P. Hüsing, S. Kohlmann, and B. Löwe, “Detecting DSM-5 somatic symptom disorder: criterion validity of the Patient Health Questionnaire-15 (PHQ-15) and the Somatic Symptom Scale-8 (SSS-8) in combination with the Somatic Symptom Disorder - B Criteria Scale (SSD-12),” Psychological medicine, vol. 50, no. 2, pp. 324–333, 2020.
[34] K. Kroenke, R. L. Spitzer, and J. B. Williams, “The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms,” Psychosomatic medicine, vol. 64, no. 2, pp. 258–266, 2002.
[35] A. Toussaint, A. M. Murray, K. Voigt, A. Herzog, B. Gierk, K. Kroenke, W. Rief, P. Henningsen, and B. Löwe, “Development and validation of the Somatic Symptom Disorder-B Criteria Scale (SSD-12),” Psychosomatic medicine, vol. 78, no. 1, pp. 5–12, 2016.
[36] M. Wei, D. W. Russell, B. Mallinckrodt, and D. L. Vogel, “The Experiences in Close Relationship Scale (ECR)-short form: reliability, validity, and factor structure,” Journal of Personality Assessment, vo. 88, no. 2, pp. 187–204, 2007.
[37] K. A. Brennan, C. L. Clark, and P. R. Shaver, “Self-report measurement of adult attachment: an integrative overview,” in Attachment theory and close relationships, J. A. Simpson and W. S. Rholes, Eds. New York: Guilford Press, 1998, pp. 46–76.
[38] K. De France and T. Hollenstein, “Assessing emotion regulation repertoires: the Regulation of Emotion Systems Survey,” Personality and Individual Differences, vol. 119, pp. 204–215, 2017.
[39] Pfizer, accessed June 2021, <https://www.phqscreeners.com>.
[40] R.-D. Kocalevent, A. Hinz, and E. Brähler, “Standardization of a screening instrument (PHQ-15) for somatization syndromes in the general population,” BMC Psychiatry, vol. 13, e91, 2013.
[41] The jamovi project, version 1.8 (Computer Software), retrieved from https://www.jamovi.org, 2021.
[42] R. C. Fraley, University of Illinois at Urbana-Champaign, 2012, accessed June 2021, <http://labs.psychology.illinois.edu/~rcfraley/measures/ecrr. htm>.
[43] S. S. Shapiro and M. B. Wilk, “An analysis of variance test for normality (complete samples),” Biometrika, vol. 52, no. 3–4, 1965, pp. 591–611.
[44] C. Croicu, L. Chwastiak, and W. Katon, “Approach to the patient with multiple somatic symptoms,” The Medical Clinics of North America, vol. 98, no. 5, pp. 1079–1095, 2014.
[45] A. Landa, M. Makous, and B. A. Fallon, “Treating somatic symptom disorder and illness anxiety in integrated care setting,” in Integrating Behavioral Health and Primary Care, R. Feinsstein, J. Connely, and M. Feinstein, Eds. Oxford: Oxford University Press, 2017, pp. 276–302.
@article{"International Journal of Medical, Medicine and Health Sciences:80602", author = "Natalia Constantinescu", title = "Attachment and Emotion Regulation among Adults with versus without Somatic Symptom Disorder", abstract = "This cross-sectional study aims to explore the differences among adults with somatic symptom disorder (SSD) versus adults without SSD, in terms of attachment and emotion regulation strategies. A total sample of 80 participants (40 people with SSD and 40 healthy controls), aged 20-57 years old (M = 31.69, SD = 10.55), were recruited from institutions and online groups. They completed the Romanian version of the Experiences in Close Relationships Scale – Short Form (ECR-S), Regulation of Emotion Systems Survey (RESS), Patient Health Questionnaire-15 (PHQ-15) and Somatic Symptom Disorder – B Criteria Scale (SSD-12). The results indicate significant differences between the two groups in terms of attachment and emotion regulation strategies. Adults with SSD have a higher level of attachment anxiety and avoidance compared to the nonclinical group. Moreover, people with SSD are more prone to use rumination and suppression and less prone to use reevaluation compared to healthy people. Implications for SSD prevention and treatment are discussed.", keywords = "adult attachment, emotion regulation strategies, psychosomatic disorders, somatic symptom disorder", volume = "15", number = "12", pages = "255-6", }
