Associations Between Adult Attachment Ratings and Health Conditions: Evidence From the National Comorbidity Survey Replication Lachlan A. McWilliams and S. Jeffrey Bailey Acadia University Objective: Attachment insecurity has been hypothesized to be a risk factor for the development of disease and chronic illness. This study was the first to investigate associations between adult attachment ratings and a wide range of health conditions. Design: Cross-sectional data from the National Comorbidity Survey Replication (N = 5645) were used. Measures: Participants completed Hazan and Shaver’s (1987) measure of adult attachment and provided reports regarding 15 health conditions. Results: Logistic regression analyses that adjusted for demographic variables indicated that avoidant attachment ratings were positively associated with conditions defined primarily by pain (e.g., frequent or severe headaches). Anxious attachment ratings were positively associated with a wider range of health conditions, including several involving the cardiovascular system (i.e., stroke, heart attack, high blood pressure). Secure attachment ratings were unrelated to the health conditions. Additional analyses investigated whether the attachment ratings accounted for unique variance in the health conditions beyond that accounted for by lifetime histories of depressive, anxiety, and alcohol- or substance-related disorders. In these analyses, anxious attachment ratings continued to have significant positive associations with chronic pain, stroke, heart attack, high blood pressure, and ulcers. Conclusion: The findings were generally supportive of the theory that insecure attachment is a risk factor for the development of disease and chronic illness, particularly conditions involving the cardiovascular system. Further research regarding the role of attachment in the development of specific health conditions is warranted. Keywords: attachment theory, cardiovascular disease, pain, ulcer, psychopathology Attachment theory (Bowlby, 1969) has been a major influence in social and developmental research over the past few decades (Roisman et al., 2007). In short, it posits an evolutionarily based system designed to ensure infants maintain proximity to caregivers during times of threat. On the basis of interactions with primary caregivers, children are thought to develop enduring cognitive schemas that continue into adulthood and guide behavior and expectations in other relationships. Responsive caregiving tends to result in the development of comfort with interpersonal closeness and a willingness to depend on others, which is referred to as secure attachment. Insecure attachment develops in response to inconsistent or unresponsive caregiving and can involve a ten- dency to be anxious regarding possible rejection, discomfort with close relationships, or both. Two approaches to adult attachment research have evolved (Bartholomew & Shaver, 1998). The devel- opmental approach has used the Adult Attachment Interview to infer states of mind regarding childhood experiences with caregiv- ers. The second approach was developed within social and per- sonality research and uses self-report measures of attachment- related thoughts and feelings in adult relationships (e.g., degree of anxiety and avoidance). Health-related research regarding attach- ment has relied almost exclusively on self-report measures of adult attachment, which involve ratings of particular attachment styles (Hazan & Shaver, 1987), or scales assessing attachment dimen- sions (Bartholomew & Horowitz, 1991) thought to underlie attach- ment styles. Attachment theory has increasingly been applied to understand- ing disease and chronic illness. Much of this work has been based on a pathoplasty model (Clark, Watson, & Mineka, 1994) that suggests that a variable (viz., insecure attachment) influences the expression or course of a disorder. For example, using a mail survey of patients with diabetes, Ciechanowski et al. (2004) found evidence that self-reports of insecure attachment were associated with poorer diabetes self-management (e.g., lower adherence to recommendations related to diet, exercise, foot care, oral hypogly- cemic medications, and smoking) and negative outcomes (e.g., elevated glycosylated hemoglobin levels). This research did not address the question of causality but rather suggested that attach- ment influences coping responses to diabetes and possibly the disorder’s severity. Similarly, in the context of chronic pain, rat- ings of insecure adult attachment have been found to be positively associated with disability levels (McWilliams, Cox, & Enns, 2000) and with depressive symptoms (Ciechanowski, Sullivan, Jensen, Romano, & Summers, 2003; Meredith, Strong, & Feeney, 2007). Predisposition models posit that vulnerability factors play a causal role in the development of a disorder (Clark et al., 1994). Related to this model, Maunder and Hunter (2001) delineated three mechanisms that could lead those with insecure attachment to have elevated rates of disease. First, those with insecure attachment have an increased susceptibility to stress, such as the tendency to perceive more stress and have more extreme physiological re- Lachlan A. McWilliams and S. Jeffrey Bailey, Department of Psychol- ogy, Acadia University. Correspondence concerning this article should be addressed to Lachlan A. McWilliams, Department of Psychology, Acadia University, Wolfville, Nova Scotia, Canada B4P 2R6. E-mail: Lachlan.Mcwilliams@acadiau.ca Health Psychology © 2010 American Psychological Association 2010, Vol. 29, No. 4, 446 – 453 0278-6133/10/$12.00 DOI: 10.1037/a0020061 446