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Psychological and Physiological Predictors of Health in Romantic Relationships: An Attachment Perspective Sarah C. E. Stanton and Lorne Campbell University of Western Ontario Abstract This article reviews the burgeoning literature linking greater individual differences in attachment anxiety and attachment avoidance to poorer health. Extant research indicates that more anxiously and avoidantly attached individuals experience heightened psychological (e.g., distress) and physiological (e.g., HPA axis activation) responses to stressful situations, as well as have poorer mental (e.g., depression) and physical (e.g., immune system functioning) health. Research also suggests that perceived social support processes are sometimes beneficial for more anxiously and avoidantly attached persons’ mental health, but are not helpful in alleviating physiological responses to stress.Future studies could fruitfully delve into the possible dyadic influences on health and interventions to improve the health experiences of more anxiously and avoidantly attached individuals. Lastly, future research could benefit from longitudinal explorations of health. The “need to belong” has been posited as a fundamental human motivation, in that individuals have a basic need to feel connected to others in enduring, close relationships (Baumeister & Leary, 1995). When asked to list the factors that make life most meaningful, the majority of people first mention satisfying close relationships, particularly romantic relationships (Berscheid, 1985). In addition to providing posi- tive affective and interpersonal benefits, social relationships influence health outcomes. Indeed, in the past few decades, researchers have established that individuals’ health status varies as a function of whether they have satisfying interper- sonal relationships and adequate perceived social support (for reviews, see Berkman, Glass, Brissette, & Seeman, 2000; Cohen, 2004; Kiecolt-Glaser & Newton, 2001; Loving & Slatcher, 2013; Uchino, 2006), such that people in long-term, satisfying relationships live longer and healthier lives than others, particularly those who are socially isolated. Interestingly, at the same time that research began to uncover important links between relationships and health, there was also a rapid growth of research focusing on the application of attachment theory to understanding adult romantic relationships. Notably, a theme common to research on relationship processes and health as well as research on individual differences in attachment and relationship processes is the importance of considering how intimate partners relate to each other and how they perceive each other’s behaviors and intentions. Perhaps not surprisingly, then, the merging of these two important research traditions since approximately the 1990s has provided significant advances to the understanding of the development of health problems in relationships (Loving & Slatcher, 2013). A goal of this article is to both review and integrate research focusing on close relationship processes, attachment orienta- tions, and health. First, we briefly discuss a few important trends in research on close relationships and well-being. We then present a brief overview of attachment theory, after which we detail specific psychological and physiological con- sequences associated with attachment system activation. Next, we review the growing literature on attachment insecurity and mental and physical health outcomes. We then discuss the role of perceived social support in influencing health experiences for more anxiously and avoidantly attached persons. Finally, we make suggestions for future research stemming from our integration of these theoretical and empirical literatures. CLOSE RELATIONSHIPSAND HEALTH Although being involved in close, interpersonal relationships (e.g., romantic relationships) is generally beneficial to indi- viduals’ health, experiences within (and the overall quality of) these relationships are important predictors of health status Correspondence concerning this article should be addressed to Sarah C. E. Stanton, Department of Psychology, Social Science Centre, University of Western Ontario, London, ON N6A 5C2, Canada. Email: [email protected]. Journal of Personality 82:6, December 2014 © 2013 Wiley Periodicals, Inc. DOI: 10.1111/jopy.12056

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Page 1: Psychological and Physiological Predictors of Health in Romantic Relationships: An Attachment Perspective

Psychological and PhysiologicalPredictors of Health inRomantic Relationships:An Attachment Perspective

Sarah C. E. Stanton and Lorne CampbellUniversity of Western Ontario

Abstract

This article reviews the burgeoning literature linking greater individual differences in attachment anxiety and attachmentavoidance to poorer health. Extant research indicates that more anxiously and avoidantly attached individuals experienceheightened psychological (e.g., distress) and physiological (e.g., HPA axis activation) responses to stressful situations, as well ashave poorer mental (e.g., depression) and physical (e.g., immune system functioning) health. Research also suggests thatperceived social support processes are sometimes beneficial for more anxiously and avoidantly attached persons’ mental health,but are not helpful in alleviating physiological responses to stress. Future studies could fruitfully delve into the possible dyadicinfluences on health and interventions to improve the health experiences of more anxiously and avoidantly attached individuals.Lastly, future research could benefit from longitudinal explorations of health.

The “need to belong” has been posited as a fundamentalhuman motivation, in that individuals have a basic need tofeel connected to others in enduring, close relationships(Baumeister & Leary, 1995). When asked to list the factors thatmake life most meaningful, the majority of people firstmention satisfying close relationships, particularly romanticrelationships (Berscheid, 1985). In addition to providing posi-tive affective and interpersonal benefits, social relationshipsinfluence health outcomes. Indeed, in the past few decades,researchers have established that individuals’ health statusvaries as a function of whether they have satisfying interper-sonal relationships and adequate perceived social support(for reviews, see Berkman, Glass, Brissette, & Seeman, 2000;Cohen, 2004; Kiecolt-Glaser & Newton, 2001; Loving &Slatcher, 2013; Uchino, 2006), such that people in long-term,satisfying relationships live longer and healthier lives thanothers, particularly those who are socially isolated.

Interestingly, at the same time that research began touncover important links between relationships and health,there was also a rapid growth of research focusing on theapplication of attachment theory to understanding adultromantic relationships. Notably, a theme common to researchon relationship processes and health as well as research onindividual differences in attachment and relationship processesis the importance of considering how intimate partners relateto each other and how they perceive each other’s behaviors andintentions. Perhaps not surprisingly, then, the merging of thesetwo important research traditions since approximately the

1990s has provided significant advances to the understandingof the development of health problems in relationships (Loving& Slatcher, 2013).

A goal of this article is to both review and integrate researchfocusing on close relationship processes, attachment orienta-tions, and health. First, we briefly discuss a few importanttrends in research on close relationships and well-being. Wethen present a brief overview of attachment theory, afterwhich we detail specific psychological and physiological con-sequences associated with attachment system activation. Next,we review the growing literature on attachment insecurity andmental and physical health outcomes. We then discuss the roleof perceived social support in influencing health experiencesfor more anxiously and avoidantly attached persons. Finally,we make suggestions for future research stemming from ourintegration of these theoretical and empirical literatures.

CLOSE RELATIONSHIPS AND HEALTHAlthough being involved in close, interpersonal relationships(e.g., romantic relationships) is generally beneficial to indi-viduals’ health, experiences within (and the overall quality of)these relationships are important predictors of health status

Correspondence concerning this article should be addressed to Sarah C. E.Stanton, Department of Psychology, Social Science Centre, University ofWestern Ontario, London, ON N6A 5C2, Canada. Email: [email protected].

Journal of Personality 82:6, December 2014© 2013 Wiley Periodicals, Inc.DOI: 10.1111/jopy.12056

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(Loving & Slatcher, 2013). For instance, since Levenson andGottman (1983) demonstrated that marital partners’ physi-ological activity is strongly related to how they interactwhile discussing problems in their relationships, the impact ofromantic relationship processes on the physiological function-ing of both partners has received widespread empirical atten-tion. At least three broad themes have emerged from this lineof research. First, marital quality and marital interactionsare directly related to physiological changes in spouses. Forexample, research indicates that wives who are less satisfiedwith their marriage have higher ambulatory blood pressure(ABP) when at home, and thus in the presence of their spouse,than while at work (Carels, Sherwood, Szczepanski, &Blumenthal, 2000), and other studies demonstrate that indi-viduals in unhappy marriages have higher ABP than singleindividuals, implying that being in a dissatisfying marriageis potentially worse than being single (Holt-Lunstad,Birmingham, & Jones, 2008).

Conflict is also associated with alterations in both bodilystress response (e.g., hormone reactivity) and immune func-tioning. In a study of 90 newlywed couples, for instance,Kiecolt-Glaser, Glaser, Cacioppo, and Malarkey (1998) foundthat hostile interactions observed while couples attempted toresolve a relationship conflict were associated with increasedlevels of epinephrine, norepinephrine, growth hormone, andadrenocorticotropic hormone as well as greater immunologicalchange over the subsequent 24 hours. This pattern of resultswas replicated in a sample of older couples who had beenmarried an average of 42 years (Kiecolt-Glaser et al., 1998).Therefore, because stressful interpersonal events can result inimmunosuppression, leaving an organism more vulnerable to avariety of illnesses (see Kiecolt-Glaser, Gouin, & Hantsoo,2010), couples who are not effective at managing marital dis-agreement may expose themselves to increased physiologicalstress over time that could leave them susceptible to healthproblems.

Second, it appears as though the presence or absence ofnegative behaviors directed toward spouses while discussingrelationship issues are more responsible for physiologicalchanges than are positive behaviors (Ewart, 1993). Forexample, hostile marital interactions (compared to neutralor positive interactions) can elevate systolic blood pressure,heart rate, and cardiac output, potentially putting individualsat greater risk for developing cardiovascular disease(Nealey-Moore, Smith, Uchino, Hawkins, & Olson-Cerny,2007). Additionally, Kiecolt-Glaser et al. (2005) found thatnegative behaviors between spouses predicted slower woundhealing and heightened levels of proinflammatory cytokines,the latter being prognostic for several diseases, including TypeII diabetes, arthritis, osteoporosis, Alzheimer’s disease, andperiodontal disease (see Kiecolt-Glaser et al., 2010).

Third, the perception of adequate partner support playsan important role in regulating physiological functioningin romantic partners (Kiecolt-Glaser, McGuire, Robles, &Glaser, 2002; Stadler, Snyder, Horn, Shrout, & Bolger, 2012;

Uchino, 2006). In general, higher levels of perceived socialsupport are related to numerous physiological markers ofhealth, including fewer age-related decrements in cardio-vascular function at rest (Uchino, Cacioppo, Malarkey, Glaser,& Kiecolt-Glaser, 1995), lower levels of catecholaminesand cortisol (Heffner, Kiecolt-Glaser, Loving, Glaser, &Malarkey, 2004; Seeman, Berkman, Blazer, & Rowe, 1994),lower levels of cortisol in women with metastatic breastcancer (Turner-Cobb, Sephton, Koopman, Blake-Mortimer, &Spiegel, 2000), fewer somatic symptoms (Stadler et al., 2012),and better immune functioning, especially for individualsexperiencing chronic stress (Esterling, Kiecolt-Glaser, Bodnar,& Glaser, 1994). This research suggests, overall, that percep-tions of higher levels of social support when coping withmoderate-to-severe stress can reduce the impact of thesestressors on individuals’ health (see also Lakey, 2013; Wills &Fegan, 2001).

This review of research on relationship processes and healthoutcomes is admittedly brief, but it highlights the importanceof specific relationship processes, as well as the perceptionsthat partners have of each other and the relationship, for under-standing short- and long-term health outcomes. The researchreviewed also implies an important role for individual differ-ences in helping to explain variability in how partners behavetoward each other and perceive each other’s behaviors andintentions, and indeed individual difference variables lendinsight into health experiences (Kiecolt-Glaser & Newton,2001). One specific theoretical framework that takes intoaccount individual differences in how people perceive andrelate to close others, and how these individual differences arerelated to health outcomes in a relationship context, is attach-ment theory (Bowlby, 1982), a topic to which we now turn ourattention.

ATTACHMENT THEORYBowlby (1973, 1980, 1982) characterized the attachmentsystem as internal working models of the self and others thatdevelop based on early interactions with significant caregivers(also called attachment figures) and guide cognition, affect,and behavior across the life span. Specifically, Bowlby pro-posed that throughout life, and particularly during infancy,humans rely on attachment figures for survival. Thus, indi-viduals cultivate beliefs about their self-worth and the depend-ability and supportiveness of others, which then organize theirexpectations of future relationships (see Baldwin, 1992; Fraley& Shaver, 2000). Attachment security develops when attach-ment figures are consistently supportive, available, and respon-sive to individuals’ needs, which in turn leads individuals tofeel that they are worthy of being loved and that they can relyon others. In contrast, attachment insecurity develops whenattachment figures are frequently rejecting, unavailable, andunresponsive to individuals’ needs, which in turn leads indi-viduals to doubt their worthiness of being loved and to ques-tion whether others can be depended on.

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After Hazan and Shaver (1987) applied attachment theoryto the study of adult romantic relationships, researchers notedthat two relatively orthogonal dimensions tap individual dif-ferences in dispositional adult attachment (see Brennan, Clark,& Shaver, 1998; Griffin & Bartholomew, 1994; Simpson,Rholes, & Phillips, 1996). According to these scholars, attach-ment anxiety reflects the tendency to worry and ruminate aboutrelationships. People who experience greater attachmentanxiety tend to crave affection in their relationships but alsofear rejection and abandonment and distrust their partners’love (Collins, 1996). Attachment avoidance, on the other hand,reflects the tendency to feel uncomfortable with closenessin relationships. People who experience greater attachmentavoidance tend to be less committed to their relationships andoften seek to remain emotionally independent from theirromantic partners (Hazan & Shaver, 1994).

ATTACHMENT SYSTEM ACTIVATIONA model detailing the activation and operation of the attach-ment system when individuals encounter threat or other stresswas developed by Mikulincer and Shaver (2003, 2007). Inbrief, when the attachment system is activated (e.g., via stress),people engage in specific behaviors toward close others.Individuals who are more securely attached (i.e., those lowin attachment anxiety and avoidance) engage in the primaryattachment strategy, proximity seeking, and draw closer toattachment figures (see Mikulincer & Shaver, 2013).

Individuals who are more insecurely attached, in contrast,have learned from early experience that proximity seeking isineffective; thus, more insecurely attached persons engage insecondary attachment strategies that involve hyperactivation ordeactivation of the attachment system. Hyperactivating strate-gies involve making stronger attempts to seek proximity andgain attention and are typically utilized by those with greaterattachment anxiety. Thus, when the attachment system is acti-vated, more anxiously attached persons attend to sources ofdistress in a hypervigilant manner and become consumedby rejection- and abandonment-related fears (Campbell &Marshall, 2011; Campbell, Simpson, Boldry, & Kashy, 2005;Shaver & Mikulincer, 2012). Deactivating strategies, incomparison, involve the inhibition of proximity seeking andare typically utilized by those with greater attachment avoid-ance. Thus, when attachment concerns are activated, moreavoidantly attached individuals deny needs and emotionalstates related to their relationships and do not turn to theirpartners for support (Mikulincer & Shaver, 2007; Simpson,Rholes, & Neligan, 1992).

Hyperactivating and deactivating strategies can be observednot only in behavior, but also at the neural level; for example,research investigating event-related potentials (ERPs) haslinked attachment insecurity with N400 amplitude (the N400is an ERP associated with integrating semantic informationinto mental representations). Specifically, within 250 ms ofencountering a threatening cue (e.g., rejection), more anx-

iously attached women (men were not included in the study)demonstrate augmented N400 (i.e., more negative-going andlonger-lasting) amplitude, whereas more avoidantly attachedwomen demonstrate dampened (i.e., less negative-goingand longer-lasting) N400 amplitude (Zayas, Shoda, Mischel,Osterhout, & Takahashi, 2009). This research reflects thecognitive processes involved in insecure attachment and alsodemonstrates that attachment system activation has both psy-chological (e.g., mental representations triggered in responseto threatening cues) and physiological (e.g., concrete neuralresponses triggered in response to threatening cues) activationpoints for more anxiously and avoidantly attached individualsin particular.

Psychological Consequences of AttachmentSystem ActivationInternal working models of attachment can lead to distinctcognitive, affective, and behavioral experiences for more inse-curely attached individuals (i.e., those higher in attachmentanxiety, attachment avoidance, or both) when the attachmentsystem is activated. For instance, more anxiously attachedindividuals tend to perceive more conflict in their relation-ships, escalate the severity of such conflict, and remain dis-tressed during a conflict discussion even when their partneracts positively and constructively toward them (Campbellet al., 2005). More avoidantly attached persons, in contrast,tend to engage in less self-disclosure (Mikulincer & Nachshon,1991) and enact negative communication patterns withinrelationships (e.g., during conflict; see Domingue & Mollen,2009).

Of particular relevance to health-related outcomes,more insecurely attached persons have an impaired ability toregulate emotions, particularly negative emotions. More anx-iously and avoidantly attached persons typically experiencenegative emotions in response to relationship-relevant events(Campbell et al., 2005), even when those events are positive innature (Mikulincer & Shaver, 2005). For example, when theirpartner behaves positively in the relationship, more secureindividuals tend to respond with joy, whereas more anxiousindividuals tend to respond with ambivalent feelings of loveand fear, and more avoidant individuals tend to respond withindifference (Mikulincer & Shaver, 2005). A greater tendencyto experience negative emotions in relationships can lead moreinsecure individuals to have trouble controlling negativity,with detrimental relationship consequences. Difficulty control-ling anger, for instance, may partially explain why attachmentanxiety and (sometimes) attachment avoidance are linked togreater intimate partner violence (see Finkel & Slotter, 2007;McNulty & Hellmuth, 2008).

Research suggests that more anxiously and avoidantlyattached individuals’ attachment systems are activated withgreater frequency. As such, the psychological consequencesof attachment system activation may “get under the skin”

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and subsequently impact mental and physical health (seePietromonaco, DeBuse, & Powers, 2013). Indeed, pooreremotion regulation is thought to yield heightened bodilyresponses to stressors, which then influence health functioning(Diamond & Fagundes, 2010, 2012).

Physiological Consequences of AttachmentSystem ActivationA growing body of research on how more anxiously andavoidantly attached individuals experience stress physiologi-cally has focused on the hypothalamic-pituitary-adrenocortical(HPA) axis and the autonomic nervous system (ANS), twomajor body systems that are activated in response to stress.Studies consistently demonstrate links between insecureattachment and augmented HPA and ANS reactivity followingstress (for reviews, see Diamond & Fagundes, 2010;Pietromonaco et al., 2013). Additionally, stressors need not bespecific to a more anxiously or avoidantly attached person’srelationship for acute bodily reactivity to occur, thoughrelationship-relevant stressors certainly trigger physiologicalresponses.

For example, more anxiously attached persons exhibitheightened HPA axis activation in the form of cortisol reactiv-ity in response to a generalized stressor (Quirin, Pruessner, &Kuhl, 2008), as well as during conflict discussions with part-ners (Powers, Pietromonaco, Gunlicks, & Sayer, 2006) andwhen physically separated from their partner for a number ofdays (Diamond, Hicks, & Otter-Henderson, 2008). Followingstress, especially if the stressor is relationship relevant, thecortisol levels of more anxious individuals take longer toreturn to baseline (e.g., Powers et al., 2006). In terms of ANSactivation, more anxiously attached individuals experiencehigher blood pressure (Gallo & Matthews, 2006) and heart rate(B. C. Feeney & Kirkpatrick, 1996; Roisman, 2007) after dis-tressing or unpleasant interactions with others, such as conflictdiscussions.

More avoidantly attached persons experience similar pat-terns of augmented HPA axis and ANS activation followingstress. These individuals also exhibit greater cortisol reactivityin response to relationship conflict (Laurent & Powers, 2007;Powers et al., 2006) or when faced with abandonment-relatedcues (Rifkin-Graboi, 2008). Additionally, more avoidant indi-viduals exhibit ANS activity in the form of increased bloodpressure, heart rate, and electrodermal reactivity in response togeneral stressors (Carpenter & Kirkpatrick, 1996; Diamond,Hicks, & Otter-Henderson, 2006; B. C. Feeney & Kirkpatrick,1996; Kim, 2006) as well as relationship-relevant stressors(Roisman, 2007).

The combination of poorer emotion regulation and height-ened bodily responses to stressors, in conjunction with a lowerthreshold for perceiving cues as stressful and/or threatening,seemingly creates a recipe for mental and immunologicalproblems for more anxiously and avoidantly attached persons.

In other words, because the psychological and physiologicalactivity associated with attachment system activation for moreinsecurely attached persons is particularly acute (Diamond &Fagundes, 2010), more avoidantly and anxiously attachedpersons are thought to be more susceptible to developingmental and physical health problems.

ATTACHMENT AND HEALTH

Mental Health and Well-BeingThe hyperactivating strategies employed by more anxiouslyattached persons do seem to undermine mental health.Research examining couples transitioning to parenthood hasfound that experiencing high anger during this transition leadsto more postnatal depressive symptoms for more anxiouswomen (Simpson, Rholes, Campbell, Tran, & Wilson, 2003).Greater attachment anxiety is also linked to engaging in morerisky health behaviors (e.g., smoking) and having poorer sleeppatterns (Scharfe & Eldredge, 2001). Lastly, more anxiouslyattached individuals have a greater risk of developingpsychopathology, such as affective disorders (Dozier, Stovall-McClough, & Albus, 1999; Ward, Lee, & Polan, 2006). Wardet al. (2006) in particular found that 100% of anxiouslyattached participants (operationalized by “preoccupied” AdultAttachment Interview [AAI] transcripts) in a communitysample received psychopathology diagnoses following theStructured Clinical Interview for DSM-III-R (SCID), suggest-ing a strong link between attachment anxiety and later possi-bility of psychopathology.

Attachment avoidance has similar links to poor mentalhealth outcomes. Roberts, Gotlib, and Kassel (1996) foundthat more avoidantly attached individuals reported moredepressive symptoms that are associated with their negativemodels of the self. These individuals also engage in more riskybehaviors and have poorer-quality sleep (Scharfe & Eldredge,2001). Research on attachment and psychopathology hasfound that more avoidantly attached persons have a greaterchance of developing psychopathology as well, particularlyAxis I disorders (Dozier et al., 1999; Ward et al., 2006). In theWard et al. (2006) study described above, 63% of avoidantlyattached participants (operationalized by “dismissing” AAItranscripts) received psychopathology diagnoses. Thus, thenegative emotional experiences of more insecurely attachedindividuals seem to predispose them to developing worsemental health down the road. Notably, and in line with attach-ment and emotion regulation research, some of the moreavoidantly attached individuals’ health issues may arise fromalexithymia, an inability to identify and talk about emotions(Wearden, Cook, & Vaughan-Jones, 2003).

Physical Health and Well-BeingResearch linking attachment insecurity and poor physicalhealth is robust for attachment anxiety. In terms of self-

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reported health, more anxious individuals report experiencingmore physical symptoms indicative of ill health, such asdigestive upsets or frequent headaches (Ciechanowski,Walker, Katon, & Russo, 2002; J. A. Feeney & Ryan, 1994).More anxious persons with disease (e.g., inflammatory boweldisease) also tend to experience more acute disease symptoms(Gick & Sirois, 2010). Physiological evidence dovetails withthese findings; for example, more anxiously attached individu-als exhibit lower levels of cardiac vagal tone, suggesting a lesshealthy heart (Diamond & Hicks, 2005). Recent research hasalso found that more anxiously attached persons have altera-tions in the hippocampus, thought to be an emotion regulationcenter. Specifically, more anxious individuals have lesshippocampal cell density (Quirin, Gillath, Pruessner, & Eggert,2010), possibly as a function of heightened neural responsesto perceived stress (Gillath, Bunge, Shaver, Wendelken, &Mikulincer, 2005). That is, when thinking about negative rela-tionship events, more anxiously attached individuals exhibitheightened activation in emotion-related areas of the brain,such as the anterior temporal pole, as well as reduced activationin emotion regulation–related areas of the brain, such as theorbitofrontal cortex (Gillath et al., 2005). Thus, because theseindividuals frequently perceive and ruminate on negativeevents in their close relationships, this activation may com-promise their ability to regulate emotions, yielding less hippo-campal cell density. Lastly, more anxious individuals haveimmunological alterations in the form of fewer helper and killerT cells (Jaremka et al., 2013). These immunological alterationsperhaps result from more anxious individuals’ chronic activa-tion of attachment concerns combined with a lower thresholdfor perceiving threat and heightened physiological activity inthe face of perceived threat (see Diamond & Fagundes, 2010),as frequent bodily stress responses can suppress the immunesystem (Kiecolt-Glaser et al., 2005).

Conversely, studies demonstrating worse physical healthexperienced as a function of greater attachment avoidanceoffer mixed results. Although some research has found thatmore avoidant individuals report experiencing more symptomsof ill health (Ciechanowski et al., 2002), other symptom-reporting research has not found these links, instead findingthat more avoidant individuals engage in limited seeking ofhealth care (J. A. Feeney & Ryan, 1994). Moreover, in theresearch conducted by Jaremka et al. (2013) discussed above,effects for attachment avoidance were nonsignificant, implyingthat more avoidantly attached persons’ physical immunesystems are not altered by attachment system activation overtime. On the other hand, more avoidant individuals with boweldisease report the disease as being more severe (Gick & Sirois,2010). Additionally, more avoidant persons exhibit less hippo-campal cell density (Quirin et al., 2010), presumably becausethese individuals also experience heightened stress responsesto negative relationship events; this in turn may partiallyinform why avoidant individuals have more difficulty regulat-ing and verbally expressing emotions (see Wearden et al.,2003). Finally, research by Gouin et al. (2009) has demon-

strated that more avoidantly attached individuals experiencegreater proinflammatory cytokine response to relationship-related conflict. While proinflammatory cytokine response isnot necessarily harmful in the short term, more frequent andamplified levels are linked with worse health and the accelera-tion of age-related diseases (see Kiecolt-Glaser et al., 2005,2010). The research by Gouin et al. (2009), therefore, suggeststhat more avoidant individuals may exhibit impaired physicalfunctioning down the road if they repeatedly encounter conflictin their intimate relationships. It may be important to note,however, that little other research has found direct alterationsin immune response for avoidant persons, both because exist-ing research does not find significant effects for avoidantattachment (e.g., Jaremka et al., 2013) and also because moreresearch on attachment and immunological alterations has yetto be conducted.

In summary, associations between insecure attachment andmental health outcomes seem robust: Both more anxiously andavoidantly attached persons tend to experience poorer psycho-logical health and well-being. The consistency of associationsbetween insecure attachment and physical health, however,appears to differ between the anxious and avoidant attachmentdimensions, with more reliable associations reported for theanxious compared to the avoidance dimension. Future researchmay potentially uncover more uniform associations betweenavoidant attachment and physical health outcomes, but it isalso possible that the differences reported in physical healthoutcomes between individuals higher in anxious and avoidantattachment reflect unique mechanisms underlying these healthoutcomes for each attachment dimension.

To be specific, one potential reason that the physical healthoutcomes of more anxious and avoidant individuals differ isthat more avoidant individuals do not seem to exhibit the sameimmunological alterations as anxious individuals. Therefore,those with greater attachment anxiety may suffer a “doublewhammy” of compromised psychological coping skills (e.g.,poor emotion regulation) as well as alterations in core immu-nity features (e.g., fewer T cells; Jaremka et al., 2013), result-ing from a relatively low threshold for activation of theirattachment concerns, that together help explain their worsemental and physical health outcomes. Individuals with greaterattachment avoidance, in comparison, may experience physicalhealth problems to the extent that they are exposed to situation-specific stressors (e.g., relationship conflict) that activatephysiological responses (e.g., cortisol, Powers et al., 2006;proinflammatory cytokines, Gouin et al., 2009). The chronicworries and concerns of more anxiously attached individualsmay therefore aid in the development of impairments to theirphysical health, whereas reactions to specific relationshipevents over time may best explain the links (when they arise)between avoidant attachment and physical health. These pos-sibilities are admittedly speculative, and future research isneeded to better understand the core mechanisms behindmental and physical health for more insecurely attachedpersons.

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PERCEIVED SOCIAL SUPPORT

As mentioned previously, perceived social support has numer-ous benefits for psychological and physical health (see Stadleret al., 2012; Uchino, 2006). For example, people who perceivegreater social support from significant others (e.g., romanticpartners) tend to have better recovery from depression(George, Blazer, Hughes, & Fowler, 1989) and have a smallerrisk of developing psychopathology (e.g., schizophrenia;Cannon et al., 2008). People who perceive greater socialsupport also tend to have lower mortality rates from cardio-vascular disease (Frasure-Smith et al., 2000), cancer (Hibbard& Pope, 1993), and infectious diseases (Lee & Rotheram-Borus, 2001). Individual differences in adult attachment,however, may represent an important moderator of the sooth-ing effects of social support on health. More specifically,because more anxiously and avoidantly attached persons havenegative representations of close others, they tend to perceiveless support available in their relationships and are less satis-fied with the support they receive (see, e.g., Bradford, J. A.Feeney, & Campbell, 2002; Campbell et al., 2005; Collins &B. C. Feeney, 2004; Gallo & Smith, 2001; Vogel & Wei, 2005).

Although a great deal of research suggests that more inse-curely attached persons have biased perceptions of socialsupport, several studies indicate that when more anxious andavoidant persons do perceive support from their partners, thissupport can have salutary psychological effects. For example,perceiving more support during a stressful life event, the tran-sition to parenthood, is associated with greater relationshipsatisfaction over time for more anxiously attached individuals(Rholes, Simpson, Campbell, & Grich, 2001). Additionally,more avoidantly attached individuals who perceive supportand experience greater relationship dependence behave morepositively in a conflict discussion (Campbell, Simpson, Kashy,& Rholes, 2001). When it comes to psychological health,therefore, the perception of greater social support may be aboon for more insecurely attached persons.

The strong physiological reactions that occur very quicklyfor more insecurely attached individuals following activationof the attachment system, however, may limit the soothingeffects of perceiving support from a partner on physical healthoutcomes. For instance, as stated in the prior section, moreanxiously and avoidantly attached individuals exhibit aug-mented physiological responses (e.g., cortisol reactivity) toboth relationship-relevant stress (Powers et al., 2006) andgeneral stress (Diamond et al., 2006; Quirin et al., 2008). Fur-thermore, more anxiously attached individuals also havealterations in cellular immunity (Jaremka et al., 2013). Itseems possible, therefore, that the deleterious effects of thesebiological mechanisms on physical health over time may notbe alleviated by perceptions of adequate social support.

To date, there are only a handful of studies investigatingattachment and the circumstances in which social supporthelps and when social support is negligible for predictingpsychological and physiological outcomes. For instance,

Meuwly et al. (2012) found that following a general stresstask, more anxious individuals’ cortisol recovered more slowlycompared to less anxious individuals, even when they receivedsocial support from their partner. Similarly, Ditzen et al.(2008) found that when more anxious individuals feel dis-tressed, social support can help attenuate these negative feel-ings; however, social support had no effects on cortisol levelsfor more anxious persons. Other research has found similareffects for more avoidantly attached persons as well (seeBrooks, Robles, & Dunkel Schetter, 2011). Taken together,these studies suggest that while perceived social support canhave salutary influences on psychological aspects of health formore insecurely attached individuals, these beneficial effectsdo not carry over to physical health outcomes to the sameextent for these individuals. Notably, this literature is in itsinfancy; studies that directly link individual differences inattachment and perceptions of social support to health out-comes beyond physiological responses to stressful situationsare still needed.

RECOMMENDATIONS FORFUTURE RESEARCHGiven the breadth of the research reviewed in this article, a(mistaken) assumption might be that little is left to uncoverregarding the links between attachment and health outcomes;however, our review suggests many gaps in the empirical lit-erature that remain to be explored. For example, research hasnot implemented longitudinal designs when investigating howthe augmented physiological stress reactivity of more inse-curely attached individuals can influence health outcomes overtime, nor have studies fully explored the dyadic influences onphysiology and health from an attachment perspective. In addi-tion, very few studies have investigated possible interventionsto improve health outcomes for more anxiously and avoidantlyattached persons. We therefore discuss several potentialavenues for future research below.

A notable limitation of the extant literature is that althoughmany studies have examined how individual differences inattachment anxiety and avoidance predict physiologicalresponses to stress and health outcomes, these processes arelargely studied in isolation. That is, the literature has much tosay about attachment and physiological reactivity to acutestressors, as well as attachment and mental and physical health,but research is more or less silent on how the augmented bodilyresponses to stress experienced by more insecurely attachedpersons result in worse health over time, and the studies that dotackle this question are largely speculative. Maunder andHunter (2001) suggested that the impaired stress regulationexperienced by more insecurely attached individuals may rep-resent one pathway through which attachment anxiety andavoidance lead to illness, but no concrete evidence currentlyexists to support this assumption. Thus, an excellent opportu-nity exists for researchers to conduct longitudinal investiga-

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tions incorporating adult attachment, acute physiologicalreactions to stress, and long-term health outcomes.

In a similar vein as the direction discussed above, noresearch has yet linked heightened physiological activation(e.g., cortisol reactivity) with mental health outcomes(e.g., depression) for more anxiously and avoidantly attachedpersons. The majority of studies examining insecure attach-ment and mental health outcomes largely focus on psychologi-cal processes (e.g., negative mental representations of othersthat in turn guide cognition, affect, and behavior throughoutlife; see Fraley & Shaver, 2000) that may facilitate the devel-opment of poor mental health and psychopathology (seeDozier et al., 1999; Simpson et al., 2003; Ward et al., 2006).There is certainly evidence that chronic stress can lead toneural activation that precipitates brain disease down the road(see de Kloet, Joëls, & Holsboer, 2005). Additionally, Quirinet al. (2010) found links between attachment insecurity andreduced hippocampal cell density, thought to partially underliethe impaired emotion regulation tendencies for such individu-als. A direct test of physiological stress response resulting innegative mental health outcomes over time from an attachmenttheory perspective, however, is still open for future studies.

Another important limitation of the current literature is thatit is primarily individual-focused (i.e., one’s personal healthoutcomes are examined as a function of one’s own attach-ment). A hitherto largely unexplored avenue for research onattachment, relationships, and health is implications one part-ner’s attachment anxiety or avoidance has for his or her part-ner’s health outcomes. Research has documented that chroniccaregiving can have detrimental effects on one’s own healthover time (Vitaliano, Zhang, & Scanlan, 2003). This has par-ticular implications for individuals with more anxiously oravoidantly attached partners, as insecure partners are morelikely to respond negatively during stressful times and havemental and physical health problems that may require frequentcaregiving.

Investigations of partner effects on health over time are stillin their infancy, but there is preliminary support for the ideathat having a more insecurely attached partner can lead topoorer health. Specifically, one study found that when PartnerA behaves in a negative way (e.g., devaluing Partner B orignoring Partner B’s displays of vulnerability), Partner B ismore likely to develop depressive symptoms three months later(Whiffen, 2005). Also, it has been shown that the partners ofmore anxiously and avoidantly attached individuals respondwith heightened physiological responses during stressful situ-ations (e.g., conflict discussions; see Powers et al., 2006), butthe mechanisms underlying these partner effects have yet to bediscovered. It is possible that the mechanisms guiding physi-ological response may be unique to having a partner who ismore anxious or more avoidant; for example, the stressresponse for the partner of a more anxiously attached indi-vidual may come from the anxious person’s action (e.g.,blaming the partner, demanding attention; see Campbell et al.,2005), whereas the stress response for the partner of a more

avoidantly attached individual may come from the avoidantperson’s inaction (e.g., shutting down, failing to acknowledgethe partner’s needs; see Simpson et al., 1992). These potentialdyadic sources of poor health outcomes over time have yet tobe systematically investigated.

Romantic relationships have a particular capacity toinfluence health (Kiecolt-Glaser & Newton, 2001; Loving &Slatcher, 2013), and as such more research on how individualdifferences in attachment influence not only one’s own but alsoone’s partner’s health is needed. Dyadic studies could furtherexplore how individual differences in attachment and interper-sonal behaviors influence psychological and physiologicalhealth processes when one partner is ill and the other mustcompensate (e.g., covering the ill partner’s chores). How part-ners navigate such circumstances may vary as a function ofattachment (e.g., a more anxiously attached partner mightblame the partner who is ill, which in turn could create addi-tional strain in the relationship). These relationship processesrelated to coping with health may thus influence not onlypsychological relationship processes (e.g., frustration thatleads to dissatisfaction in the relationship), but also health-related processes (e.g., how quickly and effectively the unwellpartner heals from his or her illness; cf. Kiecolt-Glaser et al.,2005).

Lastly, future research could fruitfully investigate interven-tions that may improve mental and physical health outcomesfor more anxiously and avoidantly attached individuals. Forinstance, gratitude training, in which individuals list up to fivethings they are grateful for daily or weekly, has been shownto positively influence well-being (e.g., improving amountand quality of sleep) and coping when dealing with disease(Emmons & McCullough, 2003). Methods of more construc-tively coping with stress, such as mindfulness-based stressreduction (MBSR), may also present opportunities to improvehealth outcomes. Cordon, Brown, and Gibson (2009) foundpreliminary support for the positive effects of MBSR on per-ceived mental stress for more insecurely attached persons;however, the potential for MBSR or other stress reductiontechniques to influence health outcomes over time has yet to beexplored. Interventions initiated at the immediate stage follow-ing stress, before more anxiously and avoidantly attached indi-viduals have time to ruminate and hyperactivate or deactivatetheir attachment systems, may be the most effective for short-and long-term outcomes.

CONCLUSIONIn this article, we focused on the psychological and physiologi-cal predictors of health in romantic relationships through thelens of attachment theory. It is well established that moreinsecurely attached individuals (i.e., those with greater attach-ment anxiety and avoidance) have acute psychological andphysiological reactions to stressful situations (e.g., conflictdiscussions). Additionally, myriad excellent studies have dem-onstrated consistent links between attachment insecurity and

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negative mental and physical health outcomes. Our reviewdoes highlight, however, that the core mechanisms underlyingpoor health outcomes for insecurely attached persons are notyet fully understood. Finally, although extant research shedslight on several important aspects of health experiences formore anxiously and avoidantly attached persons, a number ofpotentially fruitful empirical opportunities (e.g., longitudinalexplorations of health, dyadic studies of health) are amenableto future studies.

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