The Effect of Attachment Insecurity in the Development of Eating ...

The Journal of Psychology, 2010, 144(5), 449–471 C 2010 Taylor & Francis Group, LLC Copyright

The Effect of Attachment Insecurity in the Development of Eating Disturbances across Gender: The Role of Body Dissatisfaction NEFELI KOSKINA University of Athens THEODOROS GIOVAZOLIAS University of Crete

ABSTRACT. The present study examined the effects of insecure attachment on the development of negative body image as a contributing factor to the development of disturbed eating patterns in male and female university students. Participants were nonclinical male (n = 100) and female (n = 381) university students. Administering self-report questionnaires, the authors assessed demographic information (gender, age), anthropometric data (Body Mass Index [BMI], age), romantic attachment (ECRS-R; R. C. Fraley, N. G. Waller, & K. A. Brennan, 2000), body dissatisfaction (BSQ), and disturbed eating (EAT-26). The authors found body dissatisfaction to fully mediate the relationship between attachment anxiety and disordered eating in women. Body dissatisfaction mediated anxious attachment and dieting in men. In addition, attachment avoidance had a direct impact on eating behaviors for both genders, without the mediation of any variables measured in this study. The findings of the present study suggest that the anxiety and avoidance dimensions of attachment insecurity affect eating behaviors differently, and the effects are different across genders. The authors discuss results in the context of therapeutic interventions design. Keywords: body dissatisfaction, eating disorders, gender differences, insecure attachment, therapeutic interventions

PEOPLE SUFFERING FROM eating disorders often follow a chronic path and face considerable difficulties in affective processes, interpersonal relationships, and self-image. Difficulties in emotional functioning and interpersonal dependency issues seem to fit well with the emotional regulation processes and proximity-seeking behaviors described in attachment theory, as first proposed Address correspondence to Theodoros Giovazolias, Department of Psychology, University of Crete, 74100 Rethymno, Crete, Greece; [email protected] (e-mail). 449

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by John Bowlby (1969). The relationship between insecure attachment and eating disorders is well documented in a growing body of research (see O’Shaughnessy & Dallos, 2009; Ward, Ramsay, & Treasure, 2000; for recent literature reviews on empirical findings). However, little is known about the possible association of these attachment disturbances with key aspects of eating disorder psychopathology, such as body image concerns and restrained eating. For example, attachment theory can be a useful framework for conceptualizing and describing the psychological mechanisms that are involved in the interplay of body image disturbances and the development of eating disorders. Our aim was to investigate the mechanisms through which insecure romantic attachment influences eating habits, by focusing on negative body image, as a contributing factor to the development of disturbed eating. We further sought to expand the literature by exploring gender differences, an area often neglected in eating disorder research. Indeed, body image issues and eating-related problems have long been regarded as almost exclusive to women (O’Dea & Yager, 2006). Research on nonclinical populations has consistently found disturbed-eating scores for women, as measured by the Eating Attitudes Test (EAT-26), to be significantly higher than those of men (Boerner, Spillane, Anderson, & Smith, 2004; Huprich, Stepp, Graham, & Johnson, 2004). However, recent studies have shown that the problem is more prevalent in men than originally thought (Boerner et al., 2004). As many as 10% of anorexia and bulimia sufferers and 25% of the Binge Eating Disorder sufferers have been reported to be men (Weltzin et al., 2005). There is further evidence that partial or atypical syndromes of the disorders may be more prevalent in men. Woodside et al. (2001) found that when subclinical levels of symptomatology were included, men composed one third of the anorexia sample and one quarter of the bulimia sample. However, it is still argued that there is a substantial lack of research on the relationships among body image, dieting, and eating behaviors in males (O’Drea & Yager, 2006). Body Dissatisfaction and Eating Disorders Body dissatisfaction is a salient feature of disordered eating. Hilde Bruch (1973) was the first to describe body image disturbances as the critical characteristic of eating disorders, referring to anorexia as “the relentless pursuit of thinness, through self-starvation” (p. 4). The relationship between body shape concern, weight preoccupation, and eating disorders has been confirmed for young women, in cross-sectional (Erickson & Gerstre, 2007; Leon, Fulkerson, Perry, & Cudeck, 1993; Thompson & Chad, 2002) and longitudinal studies (Johnson & Wardle, 2005; Killen et al., 1994). Stice (1994, 2001) has proposed that the relation between body dissatisfaction and the development of an eating pathology is mediated via two distinct pathways: dieting and negative affect. The two pathways may coexist (Shepherd & Ricciardelli, 1998; Stice, 2001; Stice, Shaw, & Nemeroff, 1998;

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Stice & Stewart, 1999), although it seems that dietary restraint has a greater impact for the majority of young women, especially those characterized by milder bulimic symptomatology (Stice & Shaw, 2002). Body dissatisfaction is associated with fatness in both genders. Studies have found that, despite the fact than men tend to be heavier, they appear to be more satisfied with their bodies (Cash, Morrow, Hrabosky, & Perry, 2004; Davis, Dionne, & Lazarus, 1996; McKinley, 1998). It seems that women have a greater fear of being fat and are more preoccupied with dieting than are men. The most prevalent strategy used to control weight is thought to be dieting in women (Stice, 2002) and exercise in men (Drewnowski, Kurth, & Krahn, 1995). However, recent research has demonstrated the link between body dissatisfaction, dietary restraint (Heywood & McCabe, 2006; Markey & Markey, 2005), and drive for thinness (McCabe, Ricciardelli, & James, 2007) across genders.

An Attachment Perspective on Eating Disorders Attachment theory, as proposed by Bowlby (1969, 1973, 1980) through 1980, focuses on how the early interactions between infant and caregiver are decisive in shaping affect regulation strategies that become relatively stable throughout life. The first studies on attachment focused on the relationship between infant and primary caregiver. Developments in attachment research have included a growing interest in adult peer and romantic attachment, which can be understood as attachment processes parallel to early experiences (Hazan & Shaver, 1987; Shaver & Hazan, 1993). Over the past decades, attachment theory has undergone a rapid expansion. Bartholomew and Horowitz (1991) proposed a four category model of individual differences in adult attachment. More important, these categories could be organized along two orthogonal dimensions: model of self and model of other. More recent researchers have sought to reframe individual differences in attachment as arising from variation in the organization of the attachment behavioral system rather than from representations of the self and others (Fraley & Shaver, 2000). Brennan, Clark, and Shaver (1998) suggested that attachment types can be described according to two dimensions: anxiety and avoidance. Anxiety corresponds to a preoccupation about close relationships and hypervigilance regarding rejection. Avoidance refers to feeling uncomfortable with closeness and being reluctant to get close to one’s partner. Eating disorders are often described as pathologies restricted to domains of eating behavior and body image; however, they may also be related to significant difficulties in interpersonal functioning (Tasca et al., 2006). Research has found further support for Bruch’s (1973) position that central to the psychopathology of anorexia is the failure of the adolescent girl to develop autonomy and separation from parental figures (Latzer, Hochdorf, Bachar, & Canetti, 2002). Early research

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has demonstrated a consistent link between insecure attachment and eating disorders in clinical (Armstrong & Roth, 1989) and student samples (Becker, Bell, & Billington, 1987). Broberg, Hjalmers, and Nevonen (2001) compared young women who had eating disorders with a community sample and found that insecure attachment was more frequent in the clinical sample and tended to correlate with symptom severity. They found that this relationship extended to those women from the communal sample with no current symptoms who reported a previous history of an eating disorder. It therefore appears that insecure attachment organization may relate to more salient disturbances in self-image and interpersonal functioning that characterize eating disorders. Individuals with high attachment anxiety tend to depend on others for acceptance of their physical appearance (Park & Beaudet, 2007). It has been suggested that for such persons, body dissatisfaction is related to their diminished self-esteem and heightened fear of rejection (Troisi et al., 2006). According to Cole-Detke and Kobak (1996), individuals with anxious attachment are seeking to compensate for the sense of loss of personal control that they experience in interpersonal relationships, by shifting attention on their bodies and using food to regain effective control. Early separation anxiety and anxious adult attachment have been linked to body dissatisfaction in research involving women suffering from anorexia and bulimia (Troisi et al., 2006; Troisi, Massaroni, & Cuzzolaro, 2005). In a heterogeneous sample of women seeking treatment for eating disorders, Tasca et al. (2006) found that adult attachment insecurity may lead to negative affect and body dissatisfaction, the latter being linked to restrained eating. Few researchers have examined the link between attachment insecurity and body dissatisfaction in men. Elgin and Pritchard (2006a) found that risk factors associated with disturbed eating and body dissatisfaction differed between men and women. Cash, Thériault, and Annis (2004) examined a number of attachment measures, including romantic attachment, in college men and women and found that anxious romantic attachment was the strongest predictor of body image dysfunction in men and the sole predictor in women. Those authors concluded that body image concerns may be experienced as particularly salient in the context of romantic relationships, especially for young women. There is evidence that this relationship may be extended to older women in stable relationships. McKinley (1999) found a relationship between body esteem and the perception of partner approval in young women who were either married or dating and their middle-aged mothers. Evans and Wertheim (1998) found that women with eating concerns reported less satisfaction, comfort, and closeness in romantic relationships. Those authors also found an association between body dissatisfaction and the tendency to express a functional view of sexuality and other intimacy difficulties, which were mediated by general affective measures (Evans & Wertheim, 1998). Moreover, Brennan and Shaver (1995) found that disordered eating and


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body dissatisfaction correlated significantly with women’s preoccupied attachment in romantic relationships. It therefore appears that romantic attachment may be particularly relevant in exploring the role of body image concerns and eating disturbances, especially for women. Despite the convincing volume of research identifying insecure attachment as a common psychological characteristic in women suffering from eating disorders, research on male samples remains sparse. In their recent study on gender differences, using the Relationship Questionnaire (Bartholomew & Horowitz, 1991), Elgin and Pritchard (2006b) found that for men, secure attachment was significantly negatively correlated with drive for thinness, bulimia, and body dissatisfaction. However, unlike in women, insecure attachment styles did not seem to predict disordered-eating behaviors in men. Interpreting such findings may be further complicated by the often observed gender differences in adult attachment processes (Bartholomew, 1994). In their study on gender differences in pathological eating behaviors and attitudes, Huprich et al. (2004) found that for men, the EAT-26 was related to a measure of difficulties in separation–individuation, as measured by the Separation Individuation Process Inventory (SIPI; Christenson & Wilson, 1985), which correlated with attachment avoidance, while for women the EAT-26 was related to attachment anxiety on the Bell Object Relations and Reality Testing Inventory (BORRTI; Bell, 1995). Taken together, these findings suggest that, despite the large body of work, researchers have seldom examined particular symptom dimensions associated with disturbed eating, such as body image dissatisfaction, within the context of adult romantic relationships, where such concerns may be particularly salient and gender differences may be more relevant. Our goal was to investigate whether particular dimensions of romantic attachment styles can lead to disturbed eating, by contributing to body image concerns. We therefore sought to test the mediating role of body dissatisfaction in the relationship between adult romantic attachment and disordered eating. Due to the lack of research from an attachment perspective in the area of disordered eating in men, we further sought to examine this association across gender. Our central research hypothesis was that individuals with anxious attachment are more dissatisfied with their bodies and that anxious attachment predicts disturbed-eating behaviors, althrough its effect on body dissatisfaction. In addition, the possible role of avoidant attachment was examined. Also, we expected that women would have overall a more negative evaluation of their bodies and that they would be at higher risk for developing eating disorders than would men. Method Sample From 10 different departments of the University of Crete in Rethymnon, Greece, 497 students participated in this study. Of the collected questionnaires,

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16 were only partly completed (more than 15% of items were missing) and were removed from the analysis. The final sample comprised 481 participants (381 female and 100 male students). Mean age for the male subsample was 21.92 years (SD = 3.75 years), and mean age for the female subsample was 20.75 years (SD = 3.50 years). In total, 97.8% of the sample were undergraduate students. Procedure The collection of the data took place on the campus of Gallus at the University of Crete, Greece, during the 2007 spring semester. The questionnaires were filled out by the participants during an ordinary lecture. Permission by the students’ lecturers was sought before the administration of the questionnaires. There was no payment or other incentive to complete the questionnaires. Participation in the study was voluntary, and participants were informed that all results were confidential. Ethical approval was obtained from the university ethics committee. Eventually, all data were encoded, transferred, and analyzed with SPSS 15. Measures Demographic Information In total, nine questions referred to demographic information, such as gender, age, department of study, year of study, place of residence (town, village), and the educational level of both parents. Anthropometric Information Data Height and weight were reported, for the calculation of the participants’ Body Mass Index (BMI). This index is a commonly used measure of an individual’s weight, and it is calculated as the individual’s body weight (in kilos) divided by the square of their height (in meters). According to research, self-report is a reliable method of estimating BMI (Brooks-Gunn, Warren, Rosso, & Gargiulo, 1987; Shapiro & Anderson, 2003). The BMI has been found to strongly correlate with body fat (Garrow & Webster, 1985; Mei et al., 2002) and therefore provides a simple and appropriate measure of fatness. The respondents were assigned to the BMI categories according to the classification system adopted by the World Health Organization for adults over 19 years old (World Health Organization, 1995). EAT-26 The EAT-26 (Garner & Garfinkel, 1979) is a widely used self-report questionnaire that assesses behaviors related to disturbed eating and attitudes relating to body weight. It comprises 26 questions that refer to thoughts, feelings, and behaviors and that are organized into three subscales. The factor Diet (13 questions) describes the avoidance of fattening foods and preoccupation with losing weight (e.g., “I am aware of the calorie content of foods I eat”; “I engage in


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dieting behavior”). The factor Bulimia and Food Preoccupation (6 questions) includes questions that describe persistent thoughts regarding food (e.g., “I feel that food controls my life”). The part of this subscale that describes bulimia includes questions such as “I have the impulse to vomit after meals.” The third factor, Oral Control (7 questions), refers to (a) successfully controlling food intake and (b) the perceived pressure from others to eat more (e.g., “I avoid eating when I am hungry”; “I feel that others pressure me to eat”). The participants are asked to describe the degree to which they agree with these statements in a 6-point Likert-type scale including points Always, Usually, Often, Sometimes, Rarely, and Never. A high score on EAT-26 suggests a disturbed-eating behavior. The critical value of 20 has been suggested by the developers (Garner, Olmsted, Bohr, & Garfinkel, 1982) as the threshold indicating the symptomatology of a clinically identifiable disorder. For the purposes of the present study, the Greek version of the EAT-26 was used to measure levels of behavior related to eating disorders. The EAT-26 has been translated in Greek and has exhibited good psychometric properties (α = 0.81) on a Greek sample (Varsou & Trikkas, 1991). Also, it has been used in previous studies (Costarelli, Demerzi, & Stamou, 2009; Costarelli & Stamou, 2009; Yannakoulia et al., 2004) using nonclinical Greek samples. In our study, the reliability of EAT-26 was α = 0.86. For the subscales Diet (α = 0.87), Bulimia (α = 0.71), and Oral Control (α = 0.64), the reliability was considered satisfactory. Body Shape Questionnaire The Body Shape Questionnaire (BSQ-34) is a self-report questionnaire developed by Cooper, Taylor, Cooper, and Fairburn (1987) as a tool for investigating the role of body dissatisfaction in the development, progress, and therapy of anorexia nervosa and bulimia nervosa. The questionnaire comprises 34 items regarding concerns of being fat (e.g., “Have you felt so bad about your shape that you have cried?”). The questions refer to the last 4 weeks, and answers are given on a 6-point Likert type scale ranging from Never to Always. The BSQ-34 gives one single factor where high scores indicate higher levels of body dissatisfaction. High scores on the BSQ-34 (scores > 110) are correlated with the possible presence of an eating disorder (Cooper et al.). The reliability of the BSQ-34 has been reported as high (α = 0.96, OatesJohnson & Clark, 2004). It has been shown to have good convergent and criterion validity, as evidenced by its strong correlation with EAT-26 and the subscale Body Dissatisfaction of the Eating Disorders Inventory (Cooper et al., 1987). For the present study, we used the Greek version of the BSQ-34 (Angelopoulos, Tsitsas, Milionis, Blachaki, & Manios, 2006), which has good psychometric properties (α = 0.69). In our sample, the reliability of the BSQ-34 was found to be α = 0.97.

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Experiences in Close Relationships Scale—Revised The Experiences in Close Relationships Scale—Revised (ECRS-R) is a widely used self-report inventory developed by Fraley, Waller, and Brennan (2000) for the dimensional measurement of adult attachment. It comprises 36 questions describing the feeling of emotional intimacy and security in romantic relationships. Fraley’s analyses resulted in two dimensions: the insecure-anxious attachment (18 items) and the insecure-avoidant attachment (18 items) attachment. Items of the insecure-anxiety scale refer to issues of emotional dependency and the fear of rejection (e.g., “I often worry that my partner doesn’t really love me”). The insecure-avoidance scale comprises questions describing difficulties in emotional closeness (e.g., “I get uncomfortable when a romantic partner wants to be very close”). The participants indicate their agreement to the statements on a 7-point Likerttype scale ranging from Strongly Disagree to Strongly Agree, with the possibility of a Neutral/Mixed response in the middle of the scale. Low scores indicate securely attached individuals, while high scores describe emotional insecurity and difficulties with intimacy, depending on the dimension of each item (anxietyavoidance). The ECRS-R is widely used to measure romantic attachment, with excellent reliability (see Ravitz, Maunder, Hunter, Sthankiya, & Lancee, in press, for a recent review on attachment measures). It is commonly used in recent eating disorders research, in both clinical (Tasca et al., 2009) and nonclinical samples (Bamford & Halliwell, 2009). Categorical attachment measures, such as the Relationship Questionnaire (Bartholomew & Horowitz, 1991) are also commonly used (Bosmans, Goossens, & Braet, 2009). However, there is evidence to suggest that the ECRS-R has a higher reliability in measuring romantic attachment (Sibley, Fischer, & Liu, 2005). Furthermore, in analytical terms, dimensional attachment measures may be more appropriate for studying variation in romantic attachment than categorical models, which have been criticized for their limited statistical power (Fraley & Shaver, 2000). For the purposes of the present study, the ECRS-R was used to measure romantic attachment, as it is available in Greek and, more importantly, has demonstrated good validity and reliability (factor structure, criterion, convergent validity, internal consistency, and test–retest reliability). More specifically, Tsagarakis, Kafetsios, and Stalikas (2007) reported a high reliability (α = 0.91 for each dimension) and a moderate correlation (r = 0.43) between the two dimensions (anxiety and avoidance) in a Greek sample. In our sample, the reliability was α = 0.89 for the total ECRS-R (α = 0.88 and 0.86, for the subscales anxiety and avoidance, respectively). The two subscales had a moderate correlation r = 0.31 (p < .01). Data Analysis The variable EAT-26 and its three subscales had significant positive skew (z > 3.3). This finding was not surprising, given the facts that the EAT-26 measures


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clinically significant attitudes and behaviors and also that its scoring reinforces extreme scores. Subsequently, new variables were computed using logarithmic conversion. The data were analyzed using independent-samples t test, correlations, and hierarchical multiple regressions. Mediation analyses were conducted following the guidelines provided by Baron and Kenny (1986) to test the hypothesis that the relationship between insecure attachment and disordered eating is mediated by negative body image. To proceed to this kind of analysis, three conditions must be met: (a) The independent variable attachment insecurity must correlate with the mediating variable body dissatisfaction, (b) the mediating variable body dissatisfaction must correlate with the dependent variable disturbed-eating attitudes, and (c) the independent variable must correlate with the dependent variable. To speak of mediation, the effect of the independent variable on the dependent variable must be either eliminated (full mediation) or weakened (partial mediation), after the mediating variable is being controlled. The Sobel test was used to ascertain whether significant mediation occurred (Baron & Kenny). The first two requirements were fulfilled, as shown in Table 1. The third condition was tested with hierarchical multiple regression analysis. The analysis was carried out for men and women separately, with the EAT-26 and its subscales as the dependent variables and with the predicting variables being entered in accordance to the correlations observed for each gender. The alternative hypothesis that attachment insecurity (ECRS-R) is the mediating factor between negative body image (BSQ) and disordered eating (EAT-26) was examined by a series of hierarchical regression analyses, where BSQ was entered in the second block, and where attachment insecurity was entered in the third block. The results showed that BSQ did not contribute to attachment insecurity, for either of its dimensions. Similarly, BMI was not found to mediate any of the independent variables measured in this study for the prediction of EAT-26.

Results The majority of the sample (68.4%) was within the normal range of the BMI measure according to the World Health Organization classification system (World Health Organization, 1995). The percentage of the total student sample with EAT26 scores above 20 was 20.8%. Proportionately more women belonged to this group (28.7%) than did men (17.6%), albeit not to a statistically significant level, χ 2 (1, N = 481) = 2.57, df = 1, p = .109. Independent-samples t test revealed significant gender differences in romantic attachment. Men scored significantly higher on the ECRS-R, t(479) = 3.07, p < 0.05. This difference was attributed to the avoidance dimension, with men reporting being more avoidant, t(479) = 4.27, p < 0.001. Due to the gender differences in the measures studied, the variable correlations were examined separately according to gender (see Table 1).

.06 —

.00 —

—

2

—

1 .01 −.10 .81∗∗ —

−.08 .02 .78∗∗ —

−.05 .06 —

4

−.11 −.11 —

3

.00 .07 .83∗∗ .30∗∗ —

−.18 −.09 .84∗∗ .36∗∗ —

5

−.08 .40∗∗ .33∗∗ .06 .45∗∗ —

−.10 .34∗∗ .18 .05 .24∗ —

6 .02 .25∗ .24∗ .17 .22∗ .65∗∗ .74∗∗ —

−.10∗ .33∗∗ .21∗∗ .06 .27∗∗ .71∗∗ .85∗∗ —

−.16∗∗ .13∗ .22∗∗ .09 .25∗∗ .59∗∗ —

8

−.10 −.05 .20∗ .20∗ .14 .53∗∗ —

7

−.07 .14∗∗ .24∗∗ 13∗ .25∗∗ .57∗∗ .63∗∗ .56∗∗ —

−.19 .04 .16 .08 .19 .50∗∗ .66∗∗ .46∗∗ —

9

−.15∗∗ −.31∗∗ −.06 .00 −.09 −.15∗∗ .45∗∗ .07 .02 —

−.02 −.39∗∗ .04 .16 −.09 −.07 .54∗∗ .02 .15 —

10

Note. BMI = Body Mass Index; BSQ = Body Shape Questionnaire; EAT-26 = Eating Attitudes Test—26 items; EAT–Bulimia = Bulimia Subscale of EAT; EAT–Diet = Diet Subscale of EAT; EAT–Oral Control = Oral Control Subscale of EAT; ECRS-R = Experiences in Close Relationships Scale–Revised; ERCS-R–Anxiety = Anxiety dimension of the ECRS-R; ECRS-R–Avoidance = Avoidance dimension of ERCS-R. ∗ p < .05. ∗∗ p < .001.

Male students (n = 100) 1 Age 2 BMI 3 ECRS-R 4 ECRS-R–Avoidance 5 ECRS-R–Anxiety 6 BSQ 7 EAT-26 8 EAT–Diet 9 EAT–Bulimia 10 EAT–Oral Control Female students (n = 381) 1 Age 2 BMI 3 ECRS-R 4 ECRS-R–Avoidance 5 ECRS-R–Anxiety 6 BSQ 7 EAT-26 8 EAT–Diet 9 EAT–Bulimia 10 EAT–Oral Control

Subscale

TABLE 1. Intercorrelations between Subscales for Male and Female Students

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Correlations revealed (a) significant associations between BSQ and the EAT26 subscales and (b) low-to-moderate associations between the BSQ and ECRS-R dimensions, thereby meeting the conditions required for running a mediation analysis among these sets of variables. BSQ was correlated with BMI, ECRS-R–Anxiety, and the EAT-26 subscales for both genders. However, the pattern of associations appeared different between men and women with regards to the measures of disturbed eating. For men, EAT-26 correlated with insecure attachment, for a finding that we attributable to the ECRSR–Avoidance dimension (r = .20, p < 0.05). For women, EAT-26 correlated with age (r = −.16, p < 0.001), BMI (r = .13, p < 0.05), and insecure attachment, which was due to the relationship with the ECRS-R–Anxiety dimension (r = −.22, p < 0.001).

Regressions Three hierarchical regressions and subsequent mediation analyses were carried out separately for the male subsample and the female subsample. For the male subsample’s hierarchical regression model with EAT-26 as dependent variable, the predicting variables entered were the following: for Block 1, ECRS-R–Avoidance; and for Block 2, BSQ. For the female subsample’s model, the predicting variables entered were the following: for Block 1, Age and BMI; for Block 2, ECRSR–Anxiety; and for Block 3, BSQ. For the male subsample, the predicting variables ECRS-R–Avoidance and BSQ had a direct effect on the dependent variable EAT-26. The model was significant (F(1, 97) = 38.89, p < .0001), explaining 30% of the variance in the EAT-26 score. For the female subsample, the predicting variables were age, BMI, and BSQ. Attachment anxiety lost its predictive power on the EAT-26, after controlling for BSQ, exhibiting the mediating function of this variable. The model was again significant, (F (1, 347) = 128.78, p < .001), explaining 33% of the variance in the dependent variable. The Sobel test showed that the mediated effect was significant (z = 9.84, p < .000). No alternative models showed a significant mediational relationship among the variables. To further investigate the role of insecure attachment and body dissatisfaction in predicting disturbed eating, separate regressions were carried out for each of the EAT-26 subscales. For the male subsample’s hierarchical regression model with EAT-Diet as dependent variable, the predicting variables entered were the following: for Block 1, BMI; for Block 2, ECRS-R–Anxiety; and for Block 3, BSQ. For the female subsample’s model: Block 1: Age and BMI, Block 2: ECRSR–Anxiety, Block 3: BSQ (see Table 2). For both genders, BMI and ECRS-R–Anxiety were fully mediated by BSQ. The Sobel test indicated that the mediated effect of BSQ in the relationship between ECRS-Anxiety and EAT-Diet was significant for males (z = 2.33, p < .019) as well as females (z = 7.01, p < .000). For women, age also negatively predicted

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TABLE 2. Summary of Hierarchical Regression Analysis for Variables Predicting the Diet Subscale of the Eating Attitude Test (EAT–Diet) Variable Men (n = 98) Block 1 BMI Block 2 BMI ECRS-R–Anxiety Block 3 BMI ECRS-R–Anxiety BSQ Women (n = 349) Block 1 Age BMI Block 2 Age BMI ECRS-R–Anxiety Block 3 Age BMI ECRS-R–Anxiety BSQ

B

SE B

β

0.03

0.01

0.25

0.03 0.10

0.01 0.04

0.27∗ 0.24∗

0.01 0.03 0.01

0.01 0.04 0.00

0.04 0.07 0.62∗∗

−0.01 0.05

0.01 0.01

−0.09 0.33∗∗

−0.01 0.05 0.10

0.01 0.01 0.02

−0.09∗ 0.32∗∗ 0.24∗∗

−0.01 0.01 −0.02 0.01

0.01 0.01 0.02 0.00

−0.05 0.06 −0.05 0.70∗∗

Note. For the men, R2 = .05 for Step 1; R2 = .10 for Step 2; R2 = .41 for Step 3 (ps < .001). For the women, R2 = .13 for Step 1; R2 = .17 for Step 2; R2 = .49 for Step 3 (ps < .001). BMI = Body Mass Index; BSQ = Body Shape Questionnaire; ECRS-R = Experiences in Close Relationships Scale–Revised; ERCS-R–Anxiety = Anxiety dimension of the ECRS-R; ECRS-R–Avoidance = Avoidance dimension of ERCS-R. ∗ p < .05. ∗∗ p < .001.

EAT-Diet through the mediation of BSQ. Again, no alternative models showed a significant mediational relationship among the variables. For the hierarchical regression model predicting EAT-Bulimia, the predicting variable entered for the male subsample was, for Block 1, BSQ. For the female subsample’s model, the predicting variables entered were the following: for Block 1, BMI; for Block 2, ECRS-R–Avoidance and ECRS-R–Anxiety; and for Block 3, BSQ (see Table 3). For men, the only predicting variable was BSQ. For women, ECRSR–Anxiety was fully mediated by BSQ, while ECRS-R–Avoidance had a direct


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TABLE 3. Summary of Hierarchical Regression Analysis for Variables Predicting the Bulimia Subscale of the Eating Attitude Test (EAT–Bulimia) Variable Men (n = 98) Block 1 BSQ Women (n = 362) Block 1 BMI Block 2 BMI ECRS-R–Avoidance ECRS-R–Anxiety Block 3 BMI ECRS-R–Avoidance ECRS-R–Anxiety BSQ

B

SE B

0.01

0.00

0.50∗∗

0.02

0.01

0.14∗

0.01 0.02 0.07

0.01 0.02 0.02

0.12∗ 0.05 0.22∗∗

−0.01 0.04 −0.02 0.01

0.01 0.02 0.02 0.00

−0.10∗ 0.11∗ −0.06 0.62∗∗

β

Note. For the men, R2 = .24 for Step 1 (ps < .001). For the women, R2 = .02 for Step 1; R2 = .07 for Step 2; R2 = .32 for Step 3 (ps < .001). BMI = Body Mass Index; BSQ = Body Shape Questionnaire; ECRS-R = Experiences in Close Relationships Scale–Revised; ERCS-R–Anxiety = Anxiety dimension of the ECRS-R; ECRS-R–Avoidance = Avoidance dimension of ERCS-R. ∗ p < .05. ∗∗ p < .001.

predictive effect on EAT-Bulimia. The Sobel test showed that BSQ was a significant mediator of the influence of ECRS-R–Anxiety on EAT-Bulimia (z = 9.85, p < .000). BMI was partially mediated by BSQ in the same way as it was for the regression model predicting the EAT-26. No alternative models showed a significant mediational relationship among the variables examined.

Discussion Of every 5 students of our sample, 1 (20.8%) reported elevated scores on the EAT-26 (EAT-26 ≥20). It is worth noting that this rate is among the highest reported in research on student populations, both in Greece (Mpakomitrou, 2004) and worldwide (Ambrosi-Randić & Pokrajac-Bulian, 2005; Cilliers, Senekal, & Kunneke, 2006; Greenberg, Cwikel, & Mirsky, 2007; Hoerr, Bokram, Lugo, Bivins, & Keast, 2002; Koslowsky, et al., 1992; Kugu, Akyuz, Dogan, Ersan, & Izgic, 2006; Raciti & Norcross, 1987). The present study found that fatness

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was related to body dissatisfaction in both men and women, in accordance with previous research (Markey & Markey, 2005), although other studies have found that it predicts body dissatisfaction in young women, but not in men (Presnell, Bearman, & Stice, 2004). Attachment processes, in general, were found to be different between the male and female participants in our study. Men reported higher attachment avoidance than women. This finding had not been replicated in previous research on Greek student populations (Schmidt et al., 2003; Tsagarakis et al., 2007). However, it is in agreement with studies that have found men to be significantly more dismissing in romantic attachment orientation than women (Bartholomew & Horowitz, 1991; Scharfe & Bartholomew, 1994). Also, it is congruent with prescribed gender role stereotypes of women as being more attuned to their relationships and of men being oriented towards autonomy (Pietromonaco & Carnelley, 1994). Gender differences in attachment and the different way in which the two attachment insecurity dimensions contribute to the development of eating attitudes and behaviors highlight the importance of distinguishing between the two dimensions in the study of eating disorders. For the male students in our sample, attachment avoidance played a more important role in predicting EAT-26. Our findings are in agreement with those of Huprich et al. (2004), who found that for men, the EAT-26 was related to a measure that correlates with attachment avoidance, while for women, the EAT-26 was related to attachment anxiety. The model for EAT-Diet was found to explain a higher percentage of the variance for both genders, suggesting that our hypothesis is particularly relevant to behaviors concerning dieting. The subscale Diet describes preoccupation with losing weight. It has been suggested that it measures chronic failed dieting (Shepherd & Ricciardelli, 1998). Also, it has been found to correlate positively with fatness (Yannakoulia et al., 2004), a finding that was replicated in our sample (Table 1). For the regression of EAT-Diet, body image dissatisfaction was found to fully mediate anxious attachment, in both genders. This would suggest that, for the eating disturbances described in the Diet subscale, emotional dependency on the romantic partner and fear of rejection lead to a diminished body image, resulting in preoccupation with dieting, possibly in an effort to control the body’s shape and weight. This finding is consistent with past research where attachment insecurity has been linked to body dissatisfaction, which in turn may lead to restrained eating among women with eating disorders (Tasca et al., 2006). Few studies have examined the role of anxious attachment and body dissatisfaction in men (Cash, Thériault, & Annis, 2004). The present study extends past research by examining relations among insecure attachment, body dissatisfaction, and dieting behaviors in both women and men from the community, as opposed to research focusing primarily on female clinical samples (e.g., Tasca et al., 2006; Troisi et al., 2006). The mediating role of body dissatisfaction in the prediction of disturbed eating was demonstrated for both genders. However, this relationship was confined to the model for EAT-Diet in men. Taken together, these findings suggest that body


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dissatisfaction is a more robust mediator of disordered eating for women, in the context of romantic relationships. Attachment avoidance, in the female subsample, directly predicted EAT-Bulimia, while attachment anxiety was fully mediated by body dissatisfaction. Recent researchers have found attachment avoidance to have an immediate bearing on eating disorder symptoms without the mediation by emotional deactivation in women with eating disorders (Tasca et al., 2009) or social comparison in a female nonclinical population (Bryony & Halliwell, 2009). However, other mediators may play a role. For the male subsample, the only predictor of EAT-Bulimia was body dissatisfaction. This indicates that other variables outside those measured in our study may account for young men’s body image concerns, as described in the BSQ. It is possible that more suitable factors of the processes that lead men to lowered body esteem may include negative emotionality and negative self-beliefs. These factors have been found to correlate with BSQ in men, even after control for depression, while for women this manipulation tended to eliminate the relationship (Cooper, 2006). However, recent research suggested that neither positive nor negative mood states may play a role in how men feel about their bodies (Heywood & McCabe, 2006). Future research should be directed at investigating these aspects of body dissatisfaction in men more closely. For the female students of our sample, age was associated with disordered eating. Being younger was associated with the tendency to report more difficulties, while age had a positive effect, by improving eating habits. This finding is in agreement with clinical observations and past research showing significant decreases in disordered eating from late adolescence to midlife in women (Keel, Baxter, Heatherton, & Joiner, 2007). Limitations First, this study used a fairly small convenient sample (students), and therefore our results cannot be generalized to the general population. The use of a more representative sample would provide additional information on the interplay of the variables under examination. Second, there are inherent limitations in the research tools used. Results are dependent on participants’ self-reports. Our study involved both male and female students, whereas some of the questionnaires in this study were designed for research mainly on female populations. More specifically, the BSQ-34 was developed in a sample of anorectic women and measures body dissatisfaction as a function of fatness. It has often been suggested that unlike the well-documented female preference for a slim body, men tend to be less satisfied with their current muscularity (Unterhalter, Farrell, & Mohr, 2007; Vartanian, Giant, & Passino, 2001). Questionnaires that are sensitive to male preferences (McCreary, Sasse, Saucier, & Dorsch, 2004; Ochner, Gray, & Brickner, 2009) and that may be more applicable to research on body dissatisfaction in men have been recently developed. However, BSQ has been linked to higher risk of developing an eating disorder in males as well as females (Sepulveda, Carrobles, & Gandarillas,

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2008) and has been used in past research on adolescent boys (Rodr´ıguez-Cano, Beato-Fernández, & Belmonte-Llario, 2006; Beato-Fernández, Rodr´ıguez-Cano, Belmonte-Llario, & Mart´ınez-Delgado, 2004) and young adult males (PokrajacBulian & Zivicic-Becirevic, 2005). Another limitation of our study was the choice of the statistical methodology, which does not allow for the simultaneous control of two-way relationships between variables. Furthermore, the cross-sectional design limits the possibility of determining causal relationships among the variables examined. Further studies might employ a longitudinal design in order to control for these interactions. Implications for Therapy Despite the progress in understanding and treating eating disorders, a substantial proportion of people with these disorders seem to have a limited response to treatment (Kaye, Strober, Stein, & Gendall, 1999). Previous research has indicated that eating disorders may not be pathologies restricted to domains of eating behavior and body image but may also be related to significant difficulties in interpersonal functioning (Tasca et al., 2006) and that those who tend to not regulate their eating behavior are more likely to do so when they are faced with an interpersonal situation in which they feel a threat or loss (Huprich et al., 2004). According to Perlman (2005), one of the challenges in treating eatingdisordered patients is that the presenting symptoms of purging or weight gain or loss may become the clinician’s main focus, thereby reinforcing the patient’s substitution of symptom for relatedness. Attachment processes may be particularly suited for understanding eating disorders within an interpersonal context. Our research suggests that salient features of disturbed eating, such as body dissatisfaction, are linked to attachment difficulties, expressed as insecure preoccupation and fear of rejection in romantic relationships, especially in young women, thereby drawing the clinician’s focus towards relationship patterns. Also, our findings indicate that attachment difficulties expressed as fear of intimacy may be more important in shaping disordered eating in men. According to Lazarus (1993), the therapist can tailor the therapeutic distance in a way that facilitates client change. In a therapeutic approach that is informed by the attachment dimension, therapeutic engagement with a client high on attachment avoidance would be facilitated by keeping clearly defined boundaries, which would take into account the client’s difficulties with emotional intimacy. After engagement, the therapist could gradually insist on decreased therapeutic distance, to help clients with attachment avoidance overcome their fears of intimacy, offering an opportunity for a corrective emotional experience (Daly & Mallinckrodt, 2009). Tasca et al. (2009) stressed the importance of tailoring therapeutic interventions to particular attachment needs of different eating-disordered individuals. In that sense, eating-disordered patients who experience attachment anxiety may benefit from treatments that focus on affect regulation, whereas patients with attachment avoidance may require a more gradual exposure to affective expression.


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With regards to the therapeutic process, attachment processes may be particularly informing. The dimensions of anxiety and avoidance appear to have an effect on the development of specific therapeutic factors, such as the therapeutic alliance, especially in therapies that focus on interpersonal relationships (Tasca et al., 2007). People with anxious attachments tend to exaggerate their problems in order to elicit a caring response (Mikulincer, 1998), change therapists more frequently (Levy et al., 2006), and often experience a fear of losing the therapeutic relationship (Tasca, Taylor, Bissada, Ritchie, & Balfour, 2004). On the other hand, attachment avoidance has been found to relate to treatment dropout from group therapy, especially for women with eating disorders (Tasca et al., 2006; Tasca et al., 2004), and with a negative attitude towards seeking psychotherapeutic help (Riggs, Jacobvitz, & Hazen, 2002). Attachment processes can offer a promising framework for improving researchers’ and therapists’ understanding of the particular issues that this group of patients may present in the therapeutic process. In conclusion, the present authors believe that a better understanding of the relationship between attachment processes and eating disorders would enrich the conceptualization and design of therapeutic interventions, by taking into account the internal working models and attachment systems of individuals seeking help from clinical professionals. AUTHOR NOTES Nefeli Koskina is a postgraduate student in counseling psychology at the Department of Preschool Education, University of Athens, Greece. Her research interests are attachment, positive emotions, and psychological resilience. Theodoros Giovazolias is a lecturer in counseling psychology at the Department of Psychology, University of Crete, Greece. His current research interests are eating disorders, bullying and victimization, and student counseling.

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Original manuscript received January 27, 2010 Final version accepted April 8, 2010