PRACTICE REVIEW Implications of Attachment Theory and Research for the Assessment and Treatment of Eating Disorders Giorgio A. Tasca The Ottawa Hospital, Ottawa, Ontario, Canada, and University of Ottawa Kerri Ritchie The Ottawa Hospital, Ottawa, Ontario, Canada Louise Balfour The Ottawa Hospital, Ottawa, Ontario, Canada, and University of Ottawa In this paper, we review the research literature on attachment and eating disorders and suggest a framework for assessing and treating attachment functioning in patients with an eating disorder. Treatment outcomes for individuals with eating disorders tend to be moderate. Those with attachment- associated insecurities are likely to be the least to benefit from current symptom-focused therapies. We describe the common attachment categories (secure, avoidant, anxious), and then describe domains of attachment functioning within each category: affect regulation, interpersonal style, coherence of mind, and reflective functioning. We also note the impact of disorganized mental states related to loss or trauma. Assessing these domains of attachment functioning can guide focused interventions in the psychotherapy of eating disorders. Case examples are presented to illustrate assessment, case formula- tion, and group psychotherapy of eating disorders that are informed by attachment theory. Tailoring treatments to improve attachment functioning for patients with an eating disorder will likely result in better outcomes for those suffering from these particularly burdensome disorders. Keywords: attachment, eating disorders, psychological assessment, group psychotherapy During the past 30 years, attachment theory (Bowlby, 1980) has emerged as one of the most important conceptual frame- works for understanding affect regulation and human relation- ships (Mikulincer & Shaver, 2007). Also, during that period, research on eating disorders has been increasing (Theander, 2004). However, attachment theory is only recently being ap- plied to research on eating disorders (e.g., Illing, Tasca, Bal- four, & Bissada, 2010). The goal of this practice review is to conceptualize eating disorder treatment using attachment the- ory, and to orient clinicians to use attachment theory for the psychological assessment, case formulation, and psychotherapy of individuals with an eating disorder. There are three main diagnostic categories of eating disorders, namely, anorexia nervosa (AN), bulimia nervosa (BN), and eating disorders not otherwise specified (American Psychiatric Associa- tion [APA], 2000). AN is characterized by maintaining body weight at or below 15% of the normal value, and an intense fear of gaining weight. BN is characterized by recurrent binge eating, followed by inappropriate compensatory behaviors (e.g., vomit- ing). Eating disorders not otherwise specified is a category for individuals who do not meet specific criteria for AN or BN but who exhibit significant eating disorder symptoms (e.g., binge eating with no purging, i.e., binge eating disorder [BED]). Eating disorders occur predominantly in women, such that approximately 1%– 4% of adult women have a diagnosable eating disorder (APA, 2000). These individuals often suffer from comorbid psychiatric disorders such as depressive, anxiety, personality, and substance use disorders (Grilo, White, & Masheb, 2009). The mortality rate for AN is the highest among all psychiatric disorders (Agras, 2001), and the eating disorders result in very high personal and economic burden (Grenon et al., 2010). Current theories of the development of an eating disorder include the interaction of the following factors: a predisposition for low body weight in the case of AN (Bulik, Slof-Op’t Landt, van Furth, & Sullivan, 2007), or high body weight in the case of BN and BED (Williamson, Zucker, Martins, & Smeets, This article was published Online First May 23, 2011. Giorgio A. Tasca, Department of Psychology, The Ottawa Hospital, Ottawa, Ontario, Canada, and Department of Psychiatry, Faculty of Med- icine, University of Ottawa, Ottawa, Ontario, Canada; Kerri Ritchie, De- partment of Psychology, The Ottawa Hospital; Louise Balfour, Department of Psychology, The Ottawa Hospital, and Division of Infectious Diseases, Faculty of Medicine, University of Ottawa. This practice review presents two case examples that are amalgamations of a number of patients seen over many years, and not representative of particular individuals. The initials used to refer to a case and the details provided in the examples in no way could be used to identify a specific person. Correspondence concerning this article should be addressed to Giorgio A. Tasca, The Ottawa Hospital, 501 Smyth Road Box 400, Ottawa, ON, Canada, K1H8L6. E-mail: gtasca@toh.on.ca Psychotherapy © 2011 American Psychological Association 2011, Vol. 48, No. 3, 249 –259 0033-3204/11/$12.00 DOI: 10.1037/a0022423 249