December 8, 2009 — Insecure adolescents feel more intense pain and are more likely to be anxious and depressed than their secure counterparts, new research suggests.
The results of a large survey study suggest that interventions, such as cognitive behavioral therapy (CBT), that target certain attachment styles might be beneficial in teens.
“We might need to start to look at interpersonal factors like attachment styles if we want to create lasting changes in our interventions,” study author Michael J. L. Sullivan, PhD, McGill University, Montreal, Quebec, Canada, told Medscape Psychiatry.
The study was published online October 23 in the Journal of Pain.
For the study, researchers analyzed questionnaire responses from 382 high school students (223 female and 159 male). Participants were in grades 8 to 12 and had a mean age of 14.4 years.
To determine frequency and intensity of pain symptoms, researchers asked students how many times they had experienced 10 of the most frequent types of pain during the last 10 months and to rate the pain severity on an 11-point scale.
Researchers used another questionnaire to assess pain “catastrophizing” or the tendency to see symptoms as threatening or stressful. Students indicated the frequency with which they experienced each of 13 pain-related thoughts or feelings on a 5-point scale. The scale measures rumination, magnification, and helplessness.
Investigators also used the 18-item Adolescent Relationship Scale Questionnaire to assess attachment styles of students.
These styles included:
• Secure (finding it easy to get emotionally close to others);
• Preoccupied (wanting to be completely emotionally close with others);
• Fearful (worrying about being hurt if too close to others); and
• Dismissing (finding it very important to feel independent).
Students also completed questionnaires to measure the severity of symptoms of anxiety and depression.
Girls Feel More Pain
Girls in the study reported greater pain severity, pain catastrophizing, and depression than boys and had higher scores on the rumination, magnification, and helplessness subscales. Boys scored higher than girls on dismissing attachment style.
The study found various relationships between attachment styles and anxiety, depression, and pain. A secure attachment style was associated with low levels of pain catastrophizing, anxiety, pain severity, and depression, whereas preoccupied and fearful attachment styles were associated with heightened pain catastrophizing, anxiety, pain severity, and depression.
“When you start to interpret your symptoms in a more alarmist or threatening fashion, there’s a whole cascade of negative psychological and physiological events that can occur,” said Dr. Sullivan.
“If you’re experiencing pain, the more you attend to it the more you’re actually going to be experiencing more intense pain and the more you’re going to be focusing on the negative aspects of your symptoms. Over time, that might also have a wearing effect on your mood, leading to increases in anxiety and depression.”
Although it is probably expected that a secure attachment is linked to lower levels of anxiety and depression, the finding that this attachment style is related to pain severity was surprising, said Katie Cullen, MD, assistant professor of psychiatry, University of Minnesota Medical School, Minneapolis. “We wouldn’t necessarily have known what to expect with the pain, so that was really helpful,” she said.
Dr. Cullen, who was not involved in the study, runs a depression clinic, whereas her colleague, Gail A. Bernstein, MD, professor and head, Program in Child and Adolescent Anxiety and Mood Disorders, University of Minnesota Medical School, runs an anxiety clinic. Young people often present to both clinics with pain symptoms.
Insecure adolescents experience more intense pain in the form of frequent headaches, abdominal pain, and joint pain. About 20% to 25% of adolescents experience recurrent or chronic pain, according to background information in the study.
Dr. Cullen said this statistic is potentially useful in raising awareness among specialists treating teens.
In discussing the physiological mechanisms by which catastrophic thinking might influence pain severity, the study authors note that high catastrophizing has been linked to lower pain threshold and lower pain tolerance. Those with high catastrophizing show enhanced activity in brain regions involved in anticipating and attention toward pain.
Move Beyond Current CBT Model
In this study, anxiety also tended to mediate the relationship between attachment styles and both pain severity and depression. These findings suggest that anxiety, pain catastrophizing, and attachment styles are related processes that make independent contributions to the prediction of pain severity and depression.
Although the study looked at attachment styles of teenagers, these styles typically begin in infancy. “There are still a lot of holes in our knowledge in this area, but there are some fairly strong indications that the style of attachment that you develop with your parents early on is something that follows you through the rest of your life,” said Dr. Sullivan.
The study results could affect the type of interventions used to treat teens. Current cognitive behavioral interventions focus on altering catastrophic thinking but not on attachment styles that drive that thinking. Often, the positive results from such therapy do not last, said Dr. Sullivan. “This suggests that while catastrophizing is definitely one of the factors contributing to negative outcomes, it might not be the ultimate source.”
He added that it is important to “move beyond” current CBT models that might be overly simplistic. “I would strongly suspect that over the next decade, we will start to see a lot more research looking at how different interpersonal processes impact on health outcomes.”
Dr. Bernstein said she found the results “intriguing and interesting” and the sample size “impressive.” “They have a big enough sample to be drawing some conclusions, and I think it’s something that will perhaps lead to further exploration in this area.”
The authors have disclosed no relevant financial relationships.
Journal of Pain. Published online October 23, 2009.