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      Impact of attachment behavior on the treatment process of chronic pain patients

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          Insecure attachment patterns are related to the onset and development of chronic pain. However, it is less documented on how short- and long-term effects of pain therapy might differ with the attachment style in interaction with specific pain conditions. We therefore examined how two different groups of chronic pain patients differ in their treatment trajectories and in regard to attachment.


          N=85/76/67 (T1/T2/T3) patients with medically unexplained musculoskeletal pain (UMP group) were compared to n=89/76/56 patients with joint pain from osteoarthritis (OA group), using multilevel modeling. UMP patients received a multimodal pain program, and OA patients received surgery. Pain intensity before (T1) and after (T2) treatment and at a 6 months follow-up (T3) was assessed by using a visual analog scale of pain.


          Pain patients report a significant reduction in pain intensity upon the completion of the treatment compared to T1. Over the next 6 months, the pain intensity has further declined for patients with low attachment anxiety. In contrast, patients with highly anxious attachment report an increase in pain intensity. This main effect of anxious attachment on pain is significant when predicting changes both in acute treatment and during follow-up while controlling for group effect. In addition, there is also an interactive effect of group by avoidant attachment. In the UMP group, high scores in avoidant attachment were associated with the lower reduction in pain severity, while in the OA group, high scores in attachment avoidance were associated with a steeper reduction in pain severity.


          The results indicate that insecurely attached patients with pain symptoms only benefit from a multimodal pain therapy in limited ways in regard to posttreatment trajectories. Maintaining positive results over a period of 6 months is a challenge, compared with securely attached patients.


          The results of this study suggest the importance of direct and indirect mechanisms of attachment and its relevance for the management of pain experiences. Therefore, to include the individual attachment patterns in the treatment may be a promising way to enhance the treatment prospects.

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          Most cited references 32

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          On the Adaptive Control of the False Discovery Rate in Multiple Testing With Independent Statistics

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            Adult attachment in a nationally representative sample.

            The explosion of adult attachment research in the last decade has been limited by its reliance on college student and distressed samples. Using a large nationally representative sample of American adults, the authors examined the relation of sociodemographics, childhood adversity, parental representations, adult psychopathology, and personality traits to adult attachment in an effort to replicate previous findings and extend the theory. Distribution of adult attachment styles was similar to that in prior studies: 59% secure, 25% avoidant, and 11% anxious. Adult attachment was associated with several sociodemographic variables (e.g., income, age, race) not previously studied. Childhood adversities of an interpersonal nature were strongly related to insecure adult attachment. Various types of adult psychopathologies and personality traits were also strongly related to adult attachment. Implications for adult attachment theory and future research are discussed.
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              The relationship of attachment style to depression, catastrophizing and health care utilization in patients with chronic pain.

              Attachment theory and research suggest that patterns of interpersonal relationships may be important determinants of illness behavior, care seeking, and treatment response in individuals with chronic health problems, including chronic pain. Attachment styles have been shown to be associated with psychological adjustment in the context of chronic illness, but little research has been conducted so far examining these relationships in patients with chronic pain. We assessed 111 patients with chronic pain participating in a multidisciplinary pain treatment program to determine if attachment style is associated with pain, depression, catastrophizing and physical disability at pre-treatment and 12-month follow-up, and with change in health care utilization pre-treatment to follow-up. At both pre-treatment and follow-up, fearful attachment style was associated with significantly greater depression and catastrophizing, and secure attachment was associated with significantly lower levels of depression. Preoccupied attachment style was associated with greater than weekly pain-related visits at 12 months follow-up, even after controlling for depression, catastrophizing and pre-treatment pain-related health care utilization. The findings suggest that attachment style may be a useful construct for examining factors affecting adjustment and treatment response of patients with chronic pain.

                Author and article information

                J Pain Res
                J Pain Res
                Journal of Pain Research
                Journal of Pain Research
                Dove Medical Press
                01 November 2018
                : 11
                : 2653-2662
                [1 ]Department of Orthopedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, Heidelberg, Germany, ann-christin.pfeifer@ 123456med.uni-heidelberg.de
                [2 ]Institute of Medical Psychology, Center for Psychosocial Medicine, University Hospital Heidelberg, Heidelberg, Germany, ann-christin.pfeifer@ 123456med.uni-heidelberg.de
                [3 ]CONICET and Universidad de Buenos Aires, Buenos Aires, Argentina
                [4 ]School of Health Sciences, University of Surrey, Guildford, UK
                Author notes
                Correspondence: Ann-Christin Pfeifer, Department of Orthopedics, Trauma Surgery and Paraplegiology, Heidelberg University Hospital, Schlierbacher Landstr. 200a, 69118 Heidelberg, Germany, Tel +49 6221 563 5492, Email ann-christin.pfeifer@ 123456med.uni-heidelberg.de
                © 2018 Pfeifer et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

                Original Research

                Anesthesiology & Pain management

                multimodal treatment, attachment theory, chronic pain


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