Hostname: page-component-76d6cb85b7-mgxrv Total loading time: 0 Render date: 2026-07-10T06:11:18.027Z Has data issue: false hasContentIssue false
  • English
  • Français

Insecure attachment predicts depression and death anxiety in advanced cancer patients

Published online by Cambridge University Press:  15 May 2017

Katharina Scheffold ,
Rebecca Philipp ,
Susan Koranyi ,
Dorit Engelmann ,
Frank Schulz-Kindermann ,
Martin Härter  and
Anja Mehnert
Katharina Scheffold
Affiliation:
Department of Medical Psychology, University Medical Center Hamburg–Eppendorf, Hamburg, Germany
Rebecca Philipp
Affiliation:
Department of Medical Psychology, University Medical Center Hamburg–Eppendorf, Hamburg, Germany
Susan Koranyi
Affiliation:
Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Leipzig, Germany
Dorit Engelmann
Affiliation:
Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Leipzig, Germany
Frank Schulz-Kindermann
Affiliation:
Department of Medical Psychology, University Medical Center Hamburg–Eppendorf, Hamburg, Germany
Martin Härter
Affiliation:
Department of Medical Psychology, University Medical Center Hamburg–Eppendorf, Hamburg, Germany
Anja Mehnert*
Affiliation:
Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Leipzig, Germany
*
Address correspondence and reprint requests to: Anja Mehnert, Department of Medical Psychology and Medical Sociology, University Medical Center Leipzig, Philipp-Rosenthal Strasse 55, 04103 Leipzig, Germany. E-mail: anja.mehnert@medizin.uni-leipzig.de.
Get access Rights & Permissions [Opens in a new window]

Abstract

Objective:

The prevalence of depression as well as adjustment and anxiety disorders is high in advanced cancer patients, and research exploring intraindividual factors leading to high psychological distress is underrepresented. Cancer patients' feelings about security and trust in their healthcare providers have a significant influence on how they deal with their disease. The perception of social support is affected by patients' attachment styles and influences their reactions to feelings of dependency and loss of control. We therefore aimed to explore attachment and its association with psychological distress in patients with advanced cancer.

Method:

We obtained data from the baseline measurements of a randomized controlled trial in advanced cancer patients. Patients were sampled from the university medical centers of Hamburg and Leipzig, Germany. The main outcome measures included the Patient Health Questionnaire, the Death and Dying Distress Scale, the Memorial Symptom Assessment Scale, and the Experience in Close Relationships Scale for assessing attachment insecurity.

Results:

A total of 162 patients were included. We found that 64% of patients were insecurely attached (fearful-avoidant 31%, dismissing 17%, and preoccupied 16%). A dismissing attachment style was associated with more physical symptoms but did not predict psychological distress. A fearful-avoidant attachment style significantly predicted higher death anxiety and depression, whereas preoccupied attachment predicted higher death anxiety only. Overall, insecure attachment contributed to the prediction of depression (10%) and death anxiety (14%).

Significance of results:

The concept of attachment plays a relevant role in advanced cancer patients' mental health. Healthcare providers can benefit from knowledge of advanced cancer patients' attachment styles and how they relate to specific mental distress. Developing a better understanding of patients' reactions to feelings of dependency and distressing emotions can help us to develop individually tailored advanced cancer care programs and psychotherapeutic interventions.

Keywords

Advanced cancerAttachmentDepressionDeath anxiety

Information

Type
Original Article
Information
Palliative & Supportive Care , Volume 16 , Issue 3 , June 2018 , pp. 308 - 316
Copyright
Copyright © Cambridge University Press 2017 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

REFERENCES

Adelbratt, S. & Strang, P. (2000). Death anxiety in brain tumour patients and their spouses. Palliative Medicine, 14(6), 499–507.CrossRefGoogle ScholarPubMed
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. Available from http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.332.3652&rep=rep1&type=pdf.CrossRefGoogle ScholarPubMed
Bowlby, J. (1977). The making and breaking of affectional bonds, I: Aetiology and psychopathology in the light of attachment theory. An expanded version of the Fiftieth Maudsley Lecture, delivered before the Royal College of Psychiatrists, 19 November 1976. The British Journal of Psychiatry, 130(3), 201–210. Available from http://bjp.rcpsych.org/content/130/3/201.CrossRefGoogle Scholar
Brennan, K.A., Clark, C.L. & Shaver, P.R. (1998). Self-report measurement of adult attachment: An integrative overview. In Attachment Theory and Close Relationships. Simpson, J.A. & Rholes, W.S. (eds.), pp. 46–76. New York: Guilford Press.Google Scholar
Chang, V.T., Hwang, S.S., Feuerman, M., et al. (2000). The Memorial Symptom Assessment Scale Short Form (MSAS–SF). Cancer, 89(5), 1162–1171.3.0.CO;2-Y>CrossRefGoogle ScholarPubMed
Ciechanowski, P., Walker, E.A., Katon, W.J., et al. (2002). Attachment theory: A model for health care utilization and somatization. Psychosomatic Medicine, 64(4), 660–667.Google Scholar
Ciechanowski, P., Sullivan, M., Jensen, M., et al. (2003). The relationship of attachment style to depression, catastrophizing and health care utilization in patients with chronic pain. Pain, 104(10), 627–637.CrossRefGoogle ScholarPubMed
Del Giudice, M. (2011). Sex differences in romantic attachment: A meta-analysis. Personality & Social Psychology Bulletin, 37(2), 193–214.CrossRefGoogle ScholarPubMed
Engelmann, D., Scheffold, K., Friedrich, M., et al. (2016). Death-related anxiety in patients with advanced cancer: Validation of the German version of the Death and Dying Distress Scale. Journal of Pain and Symptom Management, 52(4), 582–587. Epub ahead of print Aug 9.CrossRefGoogle ScholarPubMed
Fraley, R.C. & Shaver, P.R. (2000). Adult romantic attachment: Theoretical developments, emerging controversies, and unanswered questions. Review of General Psychology, 4(2), 132–154. Available from http://academic.udayton.edu/jackbauer/Readings%20595/Fraley%2000%20attch%20rev%20copy.pdf.CrossRefGoogle Scholar
Glinska, J., Adamska, E., Lewandowska, M., et al. (2012). Evaluation of the psychological state of patients with advanced cancer and the impact of support on their emotional condition. Contemporary Oncology (Poznan, Poland), 16(6), 563–568. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3687459/.Google ScholarPubMed
Hamama-Raz, Y. & Solomon, Z. (2006). Psychological adjustment of melanoma survivors: The contribution of hardiness, attachment, and cognitive appraisal. Journal of Individual Differences, 27(3), 172–182.CrossRefGoogle Scholar
Hales, S., Lo, C. & Rodin, G. (2010). Managing Cancer and Living Meaningfully (CALM): Treatment manual. An Individual Psychotherapy for Patients with Advanced Cancer. Toronto: Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, University Health Network.Google Scholar
Holwerda, N., Sanderman, R., Pool, G., et al. (2012). Do patients trust their physician? The role of attachment style in the patient–physician relationship within one year after a cancer diagnosis. Acta Oncologica (Stockholm, Sweden), 52(1), 110–117. Epub ahead of print Nov 1. Available from http://www.rug.nl/research/portal/files/2369074/Holwerda_2013_Acta_Oncol.pdf.CrossRefGoogle ScholarPubMed
Hunter, M.J., Davis, P.J. & Tunstall, J.R. (2006). The influence of attachment and emotional support in end-stage cancer. Psycho-Oncology, 15(5), 431–444.CrossRefGoogle ScholarPubMed
Katzman, R., Brown, T., Fuld, P., et al. (1983). Validation of a short Orientation–Memory–Concentration Test of cognitive impairment. The American Journal of Psychiatry, 140(6), 734–739.Google Scholar
Kealy, D., Tsai, M. & Ogrodniczuk, J.S. (2016). Attachment style and readiness for psychotherapy among psychiatric outpatients. Psychology and Psychotherapy. Epub ahead of print. doi: 10.1111/papt.12101.Google ScholarPubMed
Kissane, D., Wein, S., Love, A., Lee, X., et al. (2004). The Demoralization Scale: A report of its development and preliminary validation. Journal of Palliative Care, 20(4), 269–276.CrossRefGoogle Scholar
Kolva, E., Rosenfeld, B., Pessin, H., et al. (2011). Anxiety in terminally ill cancer patients. Journal of Pain and Symptom Management, 42(5), 691–701. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3179568/.CrossRefGoogle ScholarPubMed
Krause, S., Rydall, A., Hales, S., et al. (2015). Initial validation of the Death and Dying Distress Scale for the assessment of death anxiety in patients with advanced cancer. Journal of Pain and Symptom Management, 49(1), 126–134. Epub ahead of print May 28, 2014.CrossRefGoogle ScholarPubMed
Kuhnt, S., Brahler, E., Faller, H., et al. (2016). Twelve-month and lifetime prevalence of mental disorders in cancer patients. Psychotherapy and Psychosomatics, 85(5), 289–296. Epub ahead of print Aug 11.CrossRefGoogle ScholarPubMed
Liu, L., Cohen, S., Schulz, M.S., et al. (2011). Sources of somatization: Exploring the roles of insecurity in relationships and styles of anger experience and expression. Social Science & Medicine, 73(9), 1436–1443. Epub ahead of print Aug 31. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3190041/.CrossRefGoogle ScholarPubMed
Lo, C., Walsh, A., Mikulincer, M., et al. (2009). Measuring attachment security in patients with advanced cancer: Psychometric properties of a modified and brief Experiences in Close Relationships Scale. Psycho-Oncology, 18(5), 490–499.CrossRefGoogle ScholarPubMed
Lo, C., Hales, S., Zimmermann, C., et al. (2011). Measuring death-related anxiety in advanced cancer: Preliminary psychometrics of the Death and Dying Distress Scale. Journal of Pediatric Hematology/Oncology, 33(Suppl. 2), S140–S145.CrossRefGoogle ScholarPubMed
Lo, C., Hales, S., Rydall, A., et al. (2015). Managing cancer and living meaningfully: Study protocol for a randomized controlled trial. Trials, 16, 391. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557481/.CrossRefGoogle ScholarPubMed
Lo, C., Hales, S., Chiu, A., et al. (2016). Managing Cancer And Living Meaningfully (CALM): Randomised feasibility trial in patients with advanced cancer. BMJ Supportive & Palliative Care, pii: bmjspcare-2015-000866. Epub ahead of print.Google ScholarPubMed
Löwe, B., Spitzer, R.L., Zipfel, S., et al. (2002). PHQ–D Gesundheitsfragebogen für Patienten. Manual Komplettversion und Kurzform: Autorisierte Deutsche Version des Prime MD Patient Health Questionnaire (PHQ), 2nd ed. [in German]. New York: Pfizer.Google Scholar
Löwe, B., Kroenke, K., Herzog, W., et al. (2004). Measuring depression outcome with a brief self-report instrument: Sensitivity to change of the Patient Health Questionnaire (PHQ–9). Journal of Affective Disorders, 81(1), 61–66.CrossRefGoogle ScholarPubMed
Maunder, R.G. & Hunter, J.J. (2009). Assessing patterns of adult attachment in medical patients. General Hospital Psychiatry, 31(2), 123–130. Epub ahead of print Dec 5, 2008.CrossRefGoogle ScholarPubMed
Maunder, R.G. & Hunter, J.J. (2016). Can patients be “attached” to healthcare providers? An observational study to measure attachment phenomena in patient–provider relationships. BMJ Open, 6), e011068. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4874120/.CrossRefGoogle ScholarPubMed
McLean, L.M. & Nissim, R. (2007). Marital therapy for couples facing advanced cancer: Case review. Palliative & Supportive Care, 5(3), 303–313.CrossRefGoogle ScholarPubMed
Mehnert, A., Müller, D., Lehmann, C. & Koch, U. (2006). Die deutsche Version des NCCN Distress-Thermometers [The German Version of the NCCN Distress Thermometer: Validation of a Screening Instrument for Assessment of Psychosocial Distress in Cancer Patients] [in German]. Zeitschrift für Psychiatrie, Psychologie und Psychotherapie, 54, 213–223.CrossRefGoogle Scholar
Meng, X., D'arcy, C. & Adams, G.C. (2015). Associations between adult attachment style and mental health care utilization: Findings from a large-scale national survey. Psychiatry Research, 229(1–2), 454–461. Epub ahead of print Jun 27.CrossRefGoogle ScholarPubMed
Meuti, V., Aceti, F., Giacchetti, N., et al. (2015). Perinatal depression and patterns of attachment: A critical risk factor? Depression Research and Treatment, 2015, 105012. Epub ahead of print Dec 20. Available from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4698776/.Google Scholar
Mikulincer, M. (1998). Attachment working models and the sense of trust: An exploration of interaction goals and affect regulation. Journal of Personality and Social Psychology, 74(5), 1209–1224.CrossRefGoogle Scholar
Mikulincer, M. & Shaver, P.R. (2007 a). Attachment in Adulthood: Structure, Dynamics, and Change. New York: Guilford Press.Google Scholar
Mikulincer, M. & Shaver, P. R. (2007 b). Boosting attachment security to promote mental health, prosocial values, and inter-group tolerance. Psychological Inquiry, 18(3), 139–156.CrossRefGoogle Scholar
Mikulincer, M., Shaver, P.R. & Pereg, D. (2003). Attachment theory and affect regulation: The dynamics, development, and cognitive consequences of attachment-related strategies. Motivation and Emotion, 27, 77–102.CrossRefGoogle Scholar
Milberg, A., Wåhlberg, R., Jakobsson, M., et al. (2012). What is a “secure base” when death is approaching? A study applying attachment theory to adult patients' and family members' experiences of palliative home care. Psycho-Oncology, 21(8), 886–895. Epub ahead of print May 6, 2011.CrossRefGoogle Scholar
Mitchell, A.J., Chan, M., Bhatti, H., et al. (2011). Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: A meta-analysis of 94 interview-based studies. The Lancet. Oncology, 12(2), 160–174.CrossRefGoogle ScholarPubMed
Nicholls, W., Hulbert-Williams, N. & Bramwell, R. (2014). The role of relationship attachment in psychological adjustment to cancer in patients and caregivers: A systematic review of the literature. Psycho-Oncology, 23(10), 1083–1095. Epub ahead of print Aug 25.CrossRefGoogle ScholarPubMed
Oldham, R.L., Dobscha, S.K., Goy, E.R., et al. (2011). Attachment styles of Oregonians who request physician-assisted death. Palliative & supportive Care, 9(2), 123–128.CrossRefGoogle ScholarPubMed
Portenoy, R.K., Thaler, H.T., Kornblith, A.B., et al. (1994). The Memorial Symptom Assessment Scale: An instrument for the evaluation of symptom prevalence, characteristics and distress. European Journal of Cancer, 30A(9), 1326–1336.CrossRefGoogle ScholarPubMed
Ravitz, P., Maunder, R., Hunter, J., et al. (2010). Adult attachment measures: A 25-year review. Journal of Psychosomatic Research, 69(4), 419–432. Epub ahead of print Dec 5, 2009.CrossRefGoogle Scholar
Rodin, G., Walsh, A., Zimmermann, C., et al. (2007). The contribution of attachment security and social support to depressive symptoms in patients with metastatic cancer. Psycho-Oncology, 16(12), 1080–1091.CrossRefGoogle ScholarPubMed
Scheffold, K., Philipp, R., Engelmann, D., et al. (2015). Efficacy of a brief manualized intervention. Managing Cancer and Living Meaningfully (CALM) adapted to German cancer care settings: Study protocol for a randomized controlled trial. BMC Cancer, 15, 592. Available from http://bmccancer.biomedcentral.com/articles/10.1186/s12885-015-1589-y.CrossRefGoogle ScholarPubMed
Spitzer, R.L., Kroenke, K. & Williams, J.B. (1999). Validation and utility of a self-report version of PRIME–MD: The PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. The Journal of the American Medical Association, 282(18), 1737–1744. Available from http://jamanetwork.com/journals/jama/fullarticle/192080.CrossRefGoogle ScholarPubMed
Tan, A., Zimmermann, C. & Rodin, G. (2005). Interpersonal processes in palliative care: An attachment perspective on the patient–clinician relationship. Palliative Medicine, 19(2), 143–150.CrossRefGoogle ScholarPubMed
Tong, E., Deckert, A., Gani, N., et al. (2016). The meaning of self-reported death anxiety in advanced cancer. Palliative Medicine, 30(8), 772–779. Epub ahead of print Feb 8.CrossRefGoogle ScholarPubMed
Wade, D.T. & Vergis, E. (1999). The Short Orientation–Memory–Concentration Test: A study of its reliability and validity. Clinical Rehabilitation, 13(2), 164–170.CrossRefGoogle Scholar
Walker, J., Holm Hansen, C., Martin, P., et al. (2013). Prevalence of depression in adults with cancer: A systematic review. Annals of Oncology, 24(4), 895–900. Epub ahead of print Nov 21, 2012. Available from https://academic.oup.com/annonc/article-lookup/doi/10.1093/annonc/mds575.CrossRefGoogle ScholarPubMed
Wiseman, H. & Tishby, O. (2014). Client attachment, attachment to the therapist and client–therapist attachment match: How do they relate to change in psychodynamic psychotherapy? Psychotherapy Research, 24(3), 392–406. Epub ahead of print Mar 20.CrossRefGoogle Scholar