Contents lists available at ScienceDirect Journal of Affective Disorders journal homepage: www.elsevier.com/locate/jad Research paper The role of emotion regulation difficulties in the relationship between attachment representations and depressive and anxiety symptoms in the postpartum period Rita Marques a , Fabiana Monteiro a,b , Maria Cristina Canavarro a,b,c , Ana Fonseca a,b, ⁎ a Faculty of Psychology and Educational Sciences, University of Coimbra, Portugal. b Center for Research in Neuropsychology and Cognitive-Behavioral Intervention (CINEICC) of the Faculty of Psychology and Educational Sciences, University of Coimbra, Portugal c Psychological Intervention Unit, Maternidade Daniel de Matos, Centro Hospitalar e Universitário de Coimbra, Portugal ARTICLE INFO Keywords: Attachment representations Anxiety symptoms Depressive symptoms Emotion regulation difficulties Postpartum period ABSTRACT Background: Insecure attachment representations have been established as a vulnerability factor for postpartum depressive symptoms. However, there is a lack of studies on the effects of attachment (in)security on postpartum anxiety symptoms, and on the mechanisms through which attachment representations may affect women's postpartum adjustment, namely, emotion regulation difficulties. Methods: The sample included 450 women in the postpartum period (up to 12 months postpartum), who were recruited both online (advertisements on social media) and in person (study was presented by the researchers during the women's postpartum hospitalization). Results: Approximately one third of the women with clinically significant symptoms (33.3%) presented co- morbid symptoms of anxiety and depression, and these women presented more insecure attachment re- presentations and more emotion regulation difficulties (p < .001) than did women without comorbid symptoms (p < .001). The relationship between more insecure attachment representations and depressive and anxiety symptoms occurred both directly and indirectly through emotional regulation difficulties. Limitations: The cross-sectional nature of the study, the use of self-report questionnaires that do not allow the establishment of clinical diagnosis and the self-selected bias in recruitment were study limitations. Conclusions: The results underline the need for attention to anxiety symptomatology, which is a condition that co-occurs frequently in this period. Interventions that focus on promoting adaptive strategies of emotional regulation are relevant rather than more intensive interventions to change attachment representations. 1. Introduction Emotional disorders in the postpartum period are an important public health issue due to their multiple negative consequences. Postpartum depression [PPD] is a prevalent clinical condition (13% in several countries) (O'Hara and McCabe, 2013) with short and long-term negative consequences to the mother, the baby, and the mother-baby interaction (Kingston et al., 2012; Woolhouse et al., 2014). Although less investigated, anxiety symptoms are also common in the postpartum period and are often associated with depressive symptoms (Falah- Hassani et al., 2016), reaching 40% in some studies (Austin et al., 2010; Reck et al., 2008). Thus, anxiety symptomatology should also be a target of research. 1.1. Attachment representations and clinically significant symptoms in the postpartum period According to Attachment Theory (Bowlby, 1969), attachment re- presentations (Hazan and Shaver, 1987; Mikulincer and Shaver, 2007; Pietromonaco and Barret, 2000) arise from the individual's early and repeated experiences with primary caregivers. These attachment re- presentations have an influence on the individual's attention, inter- pretations and memories, while also guiding the individual's interac- tions (Pietromonaco and Barret, 2000). Attachment representations are organized into two orthogonal di- mensions: anxiety and avoidance (Brennan et al., 1998). Individuals with high levels of attachment-related anxiety have insecure attach- ment representations of the self (negative self-worth), whereas https://doi.org/10.1016/j.jad.2018.05.013 Received 28 March 2018; Received in revised form 26 April 2018; Accepted 13 May 2018 ⁎ Corresponding author at: Research Group “Relationships, Development, & Health”– Center for Research in Neuropsychology and Cognitive-Behavior Intervention (CINEICC) of the Faculty of Psychology and Educational Sciences, University of Coimbra. Rua do Colégio Novo, 3001-802 Coimbra, Portugal. E-mail addresses: anadfonseca@fpce.uc.pt, ana.fonseca77@gmail.com (A. Fonseca). Journal of Affective Disorders 238 (2018) 39–46 Available online 23 May 2018 0165-0327/ © 2018 Elsevier B.V. All rights reserved. T