Relationship Between Attachment Styles and Eating ...

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Relationship Between Attachment Styles and Eating Disorder Symptomatology Among College Women a

Shannon M. Suldo & David A. Sandberg PhD

a

a

School Psychology Program, University of South Carolina, Columbia, SC, USA b

Psychology Department, California State University, Hayward, CA, USA Version of record first published: 11 Oct 2008.

To cite this article: Shannon M. Suldo & David A. Sandberg PhD (2000): Relationship Between Attachment Styles and Eating Disorder Symptomatology Among College Women, Journal of College Student Psychotherapy, 15:1, 59-73 To link to this article: http://dx.doi.org/10.1300/J035v15n01_07

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Relationship Between Attachment Styles and Eating Disorder Symptomatology Among College Women Shannon M. Suldo David A. Sandberg

ABSTRACT. This study examined the relationship between Bartholomew’s four-category model of adult attachment and eating disorder symptomatology, as measured by the Drive for Thinness, Bulimia, and Body Dissatisfaction subscales of the Eating Disorder Inventory (EDI-2), in a sample of 169 college women. Multivariate analysis revealed that only preoccupied attachment scores were positively correlated with eating disorder symptomatology. Implications for therapeutic intervention are discussed. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: Website: ]

KEYWORDS. Attachment, eating disorders, college students

The occurrence of eating disorders is disturbingly common in our society, especially among women, who are 9 times more likely than Shannon M. Suldo is Doctoral Student, School Psychology Program, University of South Carolina, Columbia, SC. David A. Sandberg, PhD, is Assistant Professor, Psychology Department, California State University, Hayward, CA. Address correspondence to: Dr. David A. Sandberg, Department of Psychology, California State University, Hayward, 25800 Carlos Bee Boulevard, Hayward, CA 94542-3091 (E-mail: [email protected]). This article is based on Shannon M. Suldo’s honors thesis at the University of North Florida, Jacksonville, Florida. The authors gratefully acknowledge LouAnne Hawkins, Mary Farley, Donna Marie Vigilante, LeeAnn Rush, Debbie Queen, Teresa Mitchell, Ellie Pegel, Nina Steighner, and Carmen Contarini for their help with data collection and for providing comments on a previous draft of this manuscript. Journal of College Student Psychotherapy, Vol. 15(1) 2000 E 2000 by The Haworth Press, Inc. All rights reserved.

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JOURNAL OF COLLEGE STUDENT PSYCHOTHERAPY

men to develop anorexia nervosa or bulimia nervosa (DSM-IV, American Psychiatric Association, 1994). Among the female population, the lifetime prevalence rate of anorexia nervosa is estimated to be .05% (Walters & Kendler, 1995). Even more women are affected by bulimia nervosa; an estimated 1% of adolescent and young women suffer from a vicious cycle of bingeing and purging (Hoek, 1993). College women are at particular risk for eating disorders. Prevalence rates of bulimia nervosa are estimated to be as high as 2% for undergraduate college women (Pyle, Neuman, Halvorson & Mitchell, 1991) and 12% to 15% for women in medical school and other graduate programs (Herzog, Norman, Rigotti, & Pepose, 1986; Herzog, Pepose, Norman, & Rigotti, 1985). Moreover, Mintz and Betz (1988) found that 64% of a sample of college women exhibited some degree of eating disordered behavior. Just as striking as the prevalence of eating disorders is their severity. A recent meta-analytic study revealed that the mortality rate of anorexia nervosa is an alarming 5.9% (Neumarker, 1997). Furthermore, anorexia nervosa, in particular, can be an extremely difficult disorder from which to recover. In one follow-up study, only 1/3 of patients with anorexia nervosa had resumed normal eating 4 to 8 years after diagnosis (Hsu, 1980). Another outcome study conducted on a clinical sample of anorexic women revealed that 36% of the original sample continued to suffer from severe eating disturbances 11 years after diagnosis, and an additional 11% had died as a result of their eating disorders (Deter & Herzog, 1994). No single cause of anorexia nervosa or bulimia nervosa has been identified. Moreover, the etiology of these disorders is likely biopsychosocial in nature; numerous factors are thought to contribute to their onset, including personality characteristics, biological predispositions, cognitive styles, family dynamics, and sociocultural pressures to be thin (Bruch, 1981; Ericsson, Poston & Foreyt, 1996; Hsu, 1990; Humphrey, 1989; Strober & Humphrey, 1987). Although each of these theoretical perspectives provides insight into the causes of eating disorders, anorexia nervosa and bulimia nervosa are far from completely understood. The onset of eating disorders typically occurs during adolescence and early adulthood, between the ages of 15 and 25 (Hoek et al., 1995; Woodside & Garfinkle, 1992). Consequently, issues specific to this developmental period (i.e., separating from parents and developing a


Shannon M. Suldo and David A. Sandberg

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sense of identity) should be examined as possible explanations for the onset and maintenance of eating disorders. Attachment theory, with its emphasis on parent-child relationships and the formation of internal working models, is one perspective that is particularly relevant to these developmental issues. According to Bowlby (1973), attachment theory is based on the belief that an infant and his or her caregiver are biologically predisposed to become attached to each other. This attachment process is crucial for the infant’s survival, in that its primary function is the protection of the infant from external threats of danger. Based on early parent-child interactions, individuals develop a system of attachment that is present throughout their lifespan; as asserted by Bowlby, ‘‘attachment behavior [characterizes] human beings from the cradle to the grave’’ (1979, p. 129). Building on the work of Bowlby, Ainsworth (1978) classified infants into three attachment styles using a laboratory procedure she developed called the ‘Strange Situation.’ The Strange Situation consists of a pattern of staged separations and reunions between the infant and his or her caregiver. Based on the infant’s responses to these separations, the infant is classified as either secure or insecure. Securely attached infants welcome their caregiver’s return and seek the caregiver for comfort. Insecurely attached infants are divided into two categories. The first insecure group consists of infants demonstrating anxious-resistant attachment; they show ambivalent behavior toward their caregiver and are unable to be comforted upon reunion with the caregiver. The other group of insecure infants is classified as avoidant; these infants characteristically avoid proximity to, or interaction with, the caregiver upon reunion. Hazan and Shaver (1987) expanded this theory of attachment to include issues of intimacy in adult relationships. They asserted that romantic love can be conceptualized as an attachment process, with the bonds between lovers being similar to the bonds between children and their parents. Each infant attachment style includes certain characteristics that correspond to the manifest behavior of adults in romantic relationships who possess that same attachment style. For example, a secure adult attachment style is characterized by ease in trusting and getting close to others. However, an adult with an anxious-ambivalent attachment style, also referred to as preoccupied, has a desire to form close relationships, and tries to mitigate fears of not being loved suffi-


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ciently by becoming enmeshed in relationships. Finally, an adult with an avoidant attachment style is uncomfortable with, skeptical of, and minimizes the importance of intimate relationships. Although limited by self-report methodology, Hazan and Shaver’s (1987) research suggested that a person’s attachment style remains relatively stable throughout the lifespan; adults’ retrospective reports of the quality of early interactions with their parents indicated continuity between infant and adult attachment styles. Moreover, longitudinal data collected by Klohnen and John (1998) yielded substantial correlations between adult attachment styles from age 25 to 52 years. Bartholomew (1990) developed a four-category model of adult attachment, which she conceptualized as an interaction between the views of self and others. Securely attached adults possess a positive view of self (i.e., they feel worthy of love) and others (i.e., they trust that their needs will be met by others), and are therefore comfortable with intimacy and autonomy. The preoccupied attachment style refers to adults who have a negative view of self and a positive view of others. Consequently, they tend to be overly dependent in relationships. Adults who possess a dismissive style characteristically deny their attachment needs. They hold a positive view of self and a negative view of others. Finally, adults with a fearful attachment style are identified by a negative view of both self and others, and are characterized by social avoidance and a fear of attachment. Essentially, Bartholomew’s classification system divides the avoidant style. Arguing that the avoidant classification umbrellas two different motivations for evading intimacy, Bartholomew created a fourth attachment style, called fearful. The distinction between the two avoidant styles is that people with an avoidant/dismissing style do not actively seek close relationships; they are aloof in relationships and do not regard them as a high priority. Conversely, those with an avoidant/fearful style are dominated by a fear of intimate relationships rather than a conscious disregard for them. Clinically, it appears that some cases of anorexia nervosa and bulimia nervosa are associated with a disruption of the attachment process during adolescence (O’Kearney, 1996). Disturbed family dynamics involving a daughter’s failure to achieve autonomy are pervasive throughout eating-disordered populations. Anorectics’ eating habits are often characterized by an issue of control, which may be due to long-term, disturbed familial interactions (Bruch, 1973). Similarly,



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people suffering from bulimia nervosa often come from disturbed families. Bulimic families are usually characterized as less cohesive, less expressive, and more conflict-ridden than non-bulimic families, suggesting that bulimics might develop feelings of insecurity and ineffectiveness because of exposure to familial conflict and hostility (Humphrey, 1989; Ordman & Kirschenbaum, 1986). Empirically, several studies have demonstrated a link between attachment difficulties and eating disorder symptomatology. Based on data obtained from 547 college women, Becker, Bell and Billington (1987), found that participants with bulimic eating patterns had significantly higher scores on an object relations subscale measuring ambivalent interpersonal relations and fear of object loss than women without these eating disturbances. Using the same object relations subscale, Heesacker and Neimeyer (1990) found similar results in a sample of 183 college women on the Drive for Thinness subscale of the Eating Disorder Inventory (EDI) and the Eating Attitudes Test (EAT). In a more recent study of a nonclinical sample of young adult women (N = 360), Evans and Wertheim (1998) found a significant relationship between eating disorder symptomatology and three dimensions of adult attachment: discomfort with closeness and intimacy, distrust toward others, and fear of abandonment. Eating disorder symptomatology was measured by a self-report bulimia screening test (BULIT-R) and the Drive for Thinness and Body Dissatisfaction subtests of the EDI. Using Bowlby’s theory of attachment, Armstrong and Roth (1989) hypothesized that anxious attachment would be a defining characteristic of patients with eating disorders. In their study, 27 eating-disordered patients and 318 nonclinical college student comparison subjects completed the Hansburg Separation Anxiety Test, a projective measure of attachment and adult separation issues. As expected, a significantly greater number of the eating-disordered inpatients exhibited anxious attachment. Unfortunately, these results are difficult to interpret because group differences were based on a comparison of psychiatric inpatients and nonclinical college students. Using Ainsworth’s (1978) three-category model of attachment (i.e., secure, anxious-ambivalent, and avoidant), Salzman (1997) found an elevation in the lifetime prevalence rate of eating disorders among college women with an anxious-ambivalent attachment style, as measured by the Adolescent Attachment Interview. Seven of 11 (64%)


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women with an anxious-ambivalent attachment style reported a history of a clinically diagnosed eating disorder; whereas none of the women with secure (n = 10) and avoidant (n = 7) attachment styles indicated such a history. Limitations of this study include its small sample size and reliance on self-report data for past diagnosis of an eating disorder. Whereas most research has found an association between anxiousambivalent, or preoccupied, attachment and eating disorder symptomatology, the results are mixed as to whether avoidant attachment is also related to eating disorder symptoms. Brennan and Shaver (1995) administered a three-category adult attachment questionnaire and the EDI to 242 male and female college students to examine how adult attachment styles relate to affect regulation and romantic relationship functioning. In this study, secure attachment ratings were negatively correlated with eating disorder symptomatology, whereas both anxious-ambivalent and avoidant attachment ratings were positively associated with the EDI subscale scores. Based on Adult Attachment Interview data obtained from 61 college women with various levels of depressive and eating disorder symptoms, Cole-Detka and Kobak (1996) found that women with deactivating attachment strategies (avoidant) had elevated levels of eating disorder symptomatology, whereas women with hyperactivating strategies (preoccupied) had increased rates of depression but not eating disorder symptoms. To date, only one study (Friedberg & Lyddon, 1996) has used Bartholomew’s 4-category model of adult attachment to examine the relation between attachment and eating disorder symptomatology. Employing Bartholomew’s model is important because it differentiates between two types of avoidant attachment (i.e., dismissing and fearful). In their study, Friedberg and Lyddon found that secure and preoccupied (but not dismissing or fearful) attachment scores discriminated between participants with and without an eating disorder diagnosis. Unfortunately, the results are potentially confounded by the study’s methodology of comparing a clinical sample of eating disordered women to a small sample of non-clinical college women. Thus, further research is needed on this topic before firm conclusions can be drawn. The purpose of this study was to investigate the relationship between Bartholomew’s 4-category model of adult attachment and eating disorder symptomatology among college women. Based on Bar-



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tholomew’s (1990) work, we hypothesized that preoccupied and fearful attachment, but not secure or dismissing, would be positively correlated with eating disorder symptomatology, as measured by the Drive for Thinness, Bulimia, and Body Dissatisfaction subscales of the Eating Disorder Inventory (EDI-2). Our hypotheses were based on the idea that both preoccupied and fearful attachment are characterized by a negative view of self, which is a central feature of women with eating disorders. In addition, we expected that preoccupied attachment would be more strongly associated than fearful attachment with eating disorder symptomatology, given this style’s prototypic need to please others. METHOD Participants Participants were 169 college women, ages 18 to 72 (M = 24.89; SD = 9.34; mode = 18), enrolled in undergraduate psychology courses at a southeastern state university. Women received extra credit in approved psychology courses in exchange for participating. Most of the participants were Caucasian (n = 123; 73%); the remaining women were African-American (n = 21; 12%), Hispanic (n = 10; 6%), Asian (n = 7; 4%) and of other ethnic background (n = 8; 5%). The majority of women were single (n = 112; 66%); the remaining participants were married (n = 29; 17%), cohabitating (n = 14; 8%), divorced (n = 7; 4%), widowed (n = 4; 2%), and separated (n = 3; 2%). Most of the women reported family incomes over $50,000 (n = 57; 34%). The remaining participants reported family incomes of less than $15,000 (n = 30; 18%), between $15,001 and $25,000 (n = 27; 16%), between $35,001 and $50,000 (n = 27; 16%) and between $25,001 and $35,000 (n = 25; 15%). Measures Relationship Questionnaire (RQ). The Relationship Questionnaire, developed by Bartholomew and Horowitz (1991), consists of four short paragraphs describing Bartholomew’s four attachment styles (secure, preoccupied, dismissing, and fearful). Each respondent is asked to read and then rate, on a 7-point subscale, the degree to which he or


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she resembles each of the four styles. The RQ has good reliability, with alpha coefficients ranging from .74 to .95 (Bartholomew & Horowitz, 1991), as well as good construct validity (Carnelly, Pietromonaco, & Jaffe, 1994; Griffen & Bartholomew, 1994). Eating Disorder Inventory-2 (EDI-2). The EDI-2 is a 91-item selfreport inventory that measures symptoms and psychological traits commonly associated with anorexia nervosa and bulimia nervosa. Respondents are asked to answer whether each item applies to them ‘‘always,’’ ‘‘usually,’’ ‘‘often,’’ ‘‘sometimes,’’ ‘‘rarely,’’ or ‘‘never.’’ Three subscales that assess attitudes and behaviors concerning eating, weight, and shape were used in this study: Drive for Thinness (excessive concern with dieting and preoccupation with weight), Bulimia (tendencies to think about and engage in bingeing), and Body Dissatisfaction (dissatisfaction with the overall shape and size of various regions of the body such as stomach, hips and buttocks). The EDI-2 has good internal consistency (reliability coefficients ranging from .81 to .93 for the three subscales used in this study) and good discriminant validity, as evidenced by the measure’s ability to successfully discriminate between eating-disordered and non-eatingdisordered samples (Garner, 1991). Procedure Data were collected during the spring, summer, and fall terms of 1998. The measures were administered to groups of approximately 10-20 women each. Women gave informed consent before participating in the study and received debriefing information after completing the questionnaires. RESULTS Sample Characteristics The means and standard deviations of the sample for the attachment ratings and the EDI-2 subscales were as follows: Secure = 4.28 (1.59), Dismissing = 3.32 (1.57), Preoccupied = 3.10 (1.88), Fearful = 3.48 (1.91), Drive for Thinness = 4.98 (6.01), Bulimia = 1.42 (3.19), and Body Dissatisfaction = 11.67 (8.56). Attachment scores have a possible range from 1 to 7 and represent the degree to which the respon-



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dent indicates she resembles each of the four attachment styles. The mean EDI-2 scores were slightly higher than published norms for college women (Garner, 1991). Associated percentile ranks were: Drive for Thinness, 64th percentile; Bulimia, 70th percentile; Body Dissatisfaction, 53rd percentile. Relationship Between Attachment Scores and Eating Disorder Symptomatology Multivariate multiple linear regression analysis was used to examine the relationship between attachment scores and eating disorder symptomatology. Because the three EDI-2 subscale scores were not normally distributed and could not be satisfactorily transformed, we dichotomized them into high and low scores. The Drive for Thinness subscale has an established clinical cutoff score of 14 (Garner, 1991). Twenty-five women (15% of our sample) scored 14 or higher. The Bulimia and Body Dissatisfaction subscales do not have clinical cutoff scores. Therefore, we dichotomized them as close as possible to the 15th percentile of our sample. Nineteen women (11% of our sample) scored 4 or higher on the Bulimia subscale, and twenty-six (15% of our sample) scored 23 or higher on the Body Dissatisfaction subscale. The four attachment scores (secure, dismissing, preoccupied, and fearful) were simultaneously entered as predictors of the three EDI-2 scores: Drive for Thinness, Bulimia, and Body Dissatisfaction. The analysis yielded a significant multivariate effect, F (12, 429) = 2.68, p = .002. Univariate analyses indicated that attachment scores were significantly associated with Drive for Thinness, F (4, 164) = 4.59, p = .002, and Bulimia, F (4, 164) = 4.84, p = .001. In addition, there was a nonsignificant trend for Body Dissatisfaction, F (4, 164) = 2.28, p = .06. Follow-up univariate regression analyses indicated that, when considered simultaneously, only preoccupied attachment scores were significantly correlated with Drive for Thinness (B = .05, SE B = .02, B = .29, p = .001) and Bulimia (B = .05, SE B = .01, B = .29, p = .001). In contrast, only dismissing attachment scores were significantly associated with Body Dissatisfaction (B = −.04, SE B = .02, B = −.19, p = .02). Whereas preoccupied attachment scores were positively correlated with Drive for Thinness and Bulimia, dismissing attachment scores were negatively correlated with Body Dissatisfaction. Bivariate


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correlations between the attachment ratings and dichotomized EDI-2 scores are shown in Table 1. DISCUSSION Our findings indicate that Bartholomew’s (1990) four attachment styles are differentially related to eating disorder symptomatology. When considered simultaneously, preoccupied attachment scores (but not secure, dismissing, or fearful) were positively correlated with Drive for Thinness and Bulimia subscale scores of the EDI-2. These results are consistent with empirical studies linking anxious-ambivalent, or preoccupied, attachment with eating disorders (Armstrong & Roth, 1989; Friedberg & Lyddon, 1996; Salzman, 1997); however, they contradict research suggesting that avoidant attachment is associated with eating disorder symptomatology (Brennan & Shaver, 1995; Cole-Detka & Kobak, 1996). Bartholomew’s (1990) 4-category model of attachment recognizes two distinct avoidant styles, which can be distinguished by a person’s positive or negative view of the self. Whereas someone with a fearful attachment style has a negative self-image and distrusts others, a person with a dismissing style maintains a positive self-image and downplays the importance of interpersonal relationships. Clinical and empirical data suggest that eating-disordered women are characterized by a negative self-concept (Bruch, 1973; Button, Loan, Davies & Sonuga-Barke, 1997; Malson, 1998; Pryor, 1998). Therefore, we had hyTABLE 1. Bivariate Correlations Between Attachment Style Ratings and Dichotomized Eating Disorder Inventory (EDI-2) Subscale Scores (N = 169) Attachment Style Ratings Eating Disorder Scores

Secure

Dismissing

Preoccupied

Fearful

Drive for Thinness

−.05

−.05

.31***

.16*

Bulimia

−.09

−.07

.31***

.16*

Body Dissatisfaction

−.11

−.17*

.10

.07

*p < .05, two-tailed. **p < .01, two-tailed. ***p < .001, two-tailed.



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pothesized that fearful attachment, but not dismissing, would also be related to eating disorder symptomatology. The finding that fearful attachment is not predictive of eating disorder symptoms is interesting because it highlights the importance of taking into account the unique and potentially destructive combination of a negative view of self and a positive view of others with regard to eating disorder symptoms. According to Bowlby (1979), attachment patterns that are formed during infancy are present throughout the lifespan. Consequently, a child who fails to develop a positive self-image due to inconsistent parenting or a lack of parental availability, who nonetheless maintains a positive view of others, is theoretically more likely to develop psychological disorders (i.e., anorexia nervosa and bulimia nervosa), whose central issues involve a disruption of a healthy self-image and an excessive need to be positively valued by others. Overly critical of their appearance and eager to please others, this type of individual might be more susceptible to socio-cultural pressures to be thin. In contrast, a child who develops a positive self-image through healthy parent-child interactions, or a child who minimizes the importance of close relationships but maintains a positive self-image despite parental maltreatment or neglect, would be at relatively decreased risk for these disorders. Clinical implications of our findings, although tentative, suggest that practitioners should be cognizant of preoccupied attachment difficulties when assessing and treating clients with eating disorders. Numerous reliable and valid measures of adult attachment are now available for client evaluation (see Brennan, Clark, and Shaver, 1998; Sperling and Berman, 1994), which could easily be administered during initial assessment at counseling centers, especially on college campuses where rates of eating disorders are relatively high. Moreover, therapeutic interventions that identify and directly modify maladaptive attachment representations (e.g., Sperling & Lyons, 1994) could be integrated into a multi-modal treatment approach (see Garner and Needleman, 1997). From an attachment perspective, the therapist should provide the client with a secure base from which he or she can identify and examine maladaptive interpersonal schemas, as well as practice new behaviors. Therapy itself should provide the client with a corrective emotional experience through which the client can reconstruct relational representations. Such approaches have the advantage of being relatively brief compared to traditional forms of dynamic


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psychotherapy, yet they maintain an interpersonal focus. Whereas cognitive-behavioral therapy has been shown to be an effective form of intervention, interpersonal models of psychotherapy for bulimia nervosa have gained increased attention in recent years (Fairburn, 1997). Although we found a significant relationship between attachment style and eating disorder symptomatology, it is important to keep in mind that anorexia nervosa and bulimia nervosa have a complex, multi-determined etiology. Preoccupied attachment is a correlate of eating disorder symptoms; however, longitudinal research is needed to determine the extent to which it actually contributes to the onset or maintenance of eating disorders. In addition, our findings require replication among clinical populations, utilizing structured diagnostic interviews for eating disorders. Despite this study’s limitations, our findings are noteworthy for two reasons. First, they emphasize the link between attachment and eating disorder symptoms. Second, they clarify that preoccupied attachment (but not secure, dismissing, or fearful) is positively correlated with eating disorder symptomatology. It is our hope that these findings stimulate further research on this important topic. REFERENCES Ainsworth, M. D., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the Strange Situation. Hillsdale, NJ: Erlbaum. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Armstrong, J. G., & Roth, D. M. (1989). Attachment and separation difficulties in eating disorders: A preliminary investigation. International Journal of Eating Disorders, 8 (2), 141-155. Bartholomew, K. (1990). Avoidance of intimacy: An attachment perspective. Journal of Social and Personal Relationships, 7, 147-178. Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four-category model. Journal of Personality and Social Psychology, 61 (2), 226-244. Becker, B., Bell, M., & Billington, R. (1987). Object relations ego deficits in bulimic college women. Journal of Clinical Psychology, 43, 92-95. Bowlby, J. (1973). Attachment and loss: Volume II: Separation. New York: Basic Books. Bowlby, J. (1979). The making and breaking of affectional bonds. London: Tavistock. Bowlby, J. (1982). Attachment and loss: Volume I: Attachment (2nd ed.). New York: Basic Books. (Original work published 1969.)



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Brennan, K. A., Clark, C. L., & Shaver, P. R. (1998). Self-report measurement of adult attachment: An integrative overview (pp. 46-76). In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and close relationships. New York: Guilford Press. Brennan, K. A., & Shaver, P. R. (1995). Dimensions of adult attachment, affect regulation, and romantic relationship functioning. Personality & Social Psychology Bulletin, 21 (3), 267-283. Bruch, H. (1973). Eating Disorders. New York: Basic Books. Bruch, H. (1981). Anorexia nervosa: Therapy and theory. The American Journal of Psychiatry, 139 (12), 1531-1538. Button, E. J., Loan, P., Davies, J., & Sonuga-Barke, E. J. (1997). Self-esteem, eating problems, and psychological well-being in a cohort of schoolgirls aged 15-16: A questionnaire and interview study. International Journal of Eating Disorders, 21 (1), 39-47. Carnelley, K. B., Pietromonaco, P. R., & Jaffe, K. (1994). Depression, working models of others, and relationship functioning. Journal of Personality and Social Psychology, 66, 127-140. Cole-Detke, H., & Kobak, R. (1996). Attachment processes in eating disorder and depression. Journal of Consulting and Clinical Psychology, 64, 282-290. Deter, H., & Herzog, W. (1994). Anorexia nervosa in a long-term perspective: Results of the Heidelberg-Mannheim study. Psychosomatic Medicine, 56, 20-27. Ericsson, M., Poston, W. S., & Foreyt, J. P. (1996). Common biological pathways in eating disorders and obesity. Addictive Behaviors, 21 (6), 733-743. Evans, L., & Wertheim, E. (1998). Intimacy patterns and relationship satisfaction of women with eating problems and the mediating effects of depression, trait anxiety and social anxiety. Journal of Psychosomatic Research, 44, 355-365. Fairburn, C. G. (1997). Interpersonal psychotherapy for bulimia nervosa (pp. 278294). In D. M. Garner, P. E. Garfinkel et al. (Eds.) Handbook of treatment for eating disorders (2nd edition). New York: Guilford Press. Friedberg, N. L., & Lyddon, W. J. (1996). Self-other working models and eating disorders. Journal of Cognitive Psychotherapy: An International Quarterly, 10 (3), 193-203. Garner, D. M. (1991). EDI-2: Eating disorders inventory-2 professional manual. Odessa, FL: Psychological Assessment Resources. Griffin, D., & Bartholomew, K. (1994). Models of self and other: Fundamental dimensions underlying measures of attachment. Journal of Personality and Social Psychology, 67 (3), 430-445. Hazan, C., & Shaver, P. (1987). Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology, 52 (3), 511-524. Heesacker, R., & Neimeyer, G. (1990). Assessing object relations and social cognitive correlates of eating disorder. Journal of Counseling and Clinical Psychology, 37, 419-426. Herzog, D. B., Norman, D. K., Rigotti, N. A., & Pepose, M. (1986). Frequency of bulimic behaviors and associated social maladjustment in female graduate students. Journal of Psychiatric Research, 20 (4), 355-361. Herzog, D. B., Pepose, M., Norman, D. K., & Rigotti, N. A. (1985). Eating disorders


72


and social maladjustment in female medical students. Journal of Nervous & Mental Disease, 173 (12), 734-737. Hoek, H. W. (1993). Review of the epidemiological studies of eating disorders. International Review of Psychiatry, 5 (1), 61-74. Hoek, H. W., Bartelds, A. I., Bosveld, J. J., Van der Graaf, Y., Limpens, V. E., Maiwald, M., & Spaaij, C. J. (1995). Impact of urbanization on detection rates of eating disorders. American Journal of Psychiatry, 152 (9), 1272-1278. Hsu, L. K. (1980). Outcome of anorexia nervosa: A review of the literature (1954 to 1978). Archives of General Psychiatry, 37 (9), 1041-1046. Hsu, L. K. (1990). Eating Disorders. New York: Guilford Press. Humphrey, L. L. (1989). Observed family interactions among subtypes of eating disorders using structural analysis of social behavior. Journal of Consulting and Clinical Psychology, 57 (2), 206-214. Klohnen, E. C., & John, O. P. (1998). Working models of attachment: A theory-based prototype approach (pp. 115-140). In J. A. Simpson & W. S. Rholes (Eds.), Attachment theory and close relationships. New York: Guilford Press. Malson, H. (1998). The thin woman. New York: Routledge. Mintz, L., & Betz, N. (1988). Prevalence and correlates of eating disordered behaviors among undergraduate women. Journal of Counseling Psychology, 35, 463-471. Neumarker, K. (1997). Mortality and sudden death in anorexia nervosa. International Journal of Eating Disorders, 21 (3), 205-212. O’Kearney, R. (1996). Attachment disruption in anorexia nervosa and bulimia nervosa: A review of theory and empirical research. International Journal of Eating Disorders, 20 (2), 115-127. Ordman, A. M., & Kirschenbaum, D. S. (1986). Bulimia: Assessment of eating, psychological adjustment, and familial characteristics. International Journal of Eating Disorders, 5 (5), 865-878. Pryor, T. (1998). Personality features and expressed concerns of adolescents with eating disorders. Adolescence, 33 (130), 291-300. Pyle, R. L., Neuman, P. A., Halvorson, P. A., & Mitchell, J. E. (1991). An ongoing cross-sectional study of the prevalence of eating disorders in freshman college students. International Journal of Eating Disorders, 10 (6), 667-677. Salzman, J. P. (1997). Ambivalent attachment in female adolescents: Association with affective instability and eating disorders. International Journal of Eating Disorders, 21, 251-259. Simpson, J. A., & Rholes, W. S. (1998). Attachment theory and close relationships. New York: Guilford Press. Sperling, M. B., & Berman, W. H. (Eds.). (1994). Attachment in adults: Clinical and developmental perspectives. New York: Guilford Press. Sperling, M. B., & Lyons, L. S. (1994). Representations of attachment and psychotherapeutic change (pp. 331-347). In M. B. Sperling & W. H. Berman (Eds.), Attachment in adults: Clinical and developmental perspectives. New York: Guilford Press. Strober, M., & Humphrey, L. L. (1987). Familial contributions of the etiology and



73

course of anorexia nervosa and bulimia. Journal of Consulting and Clinical Psychology, 55 (5), 654-659. Walters, E. E., & Kendler, K. S. (1995). Anorexia nervosa and anorexic-like syndromes in a population-based female twin sample. American Journal of Psychiatry, 152 (1), 64-71. Woodside, D. B., & Garfinkel, P. E. (1992). Age of onset in eating disorders. International Journal of Eating Disorders, 12 (1), 31-36.

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