The Role of Emotion Regulation in the Association of Adult Attachment and Mental Health: a Systematic Review Zeinab Mortazavizadeh, Simon Forstmeier*

Mortazavizadeh Z. et al. Archives of Psychology, vol. 2, issue 9, September 2018 Page 1 of 25

REVIEW ARTICLE The role of emotion regulation in the association of adult attachment and mental health: A systematic review Zeinab Mortazavizadeh, Simon Forstmeier*

Authors' affiliations: Developmental Psychology, University of Siegen, Siegen, Germany

* Corresponding Author: Prof. Dr. Simon Forstmeier, University of Siegen, Faculty II – Dept. of Education Studies & Psychology, Developmental Psychology, Adolf-Reichwein-Str. 2a, 57068 Siegen, Germany, Email: [email protected], Phone +49 (0)271 740-4020, Fax +49 (0)271 740-4555, ORCID: 0000-0003-0580-1512

Abstract Attachment style is one of the most significant driving forces across the lifespan as identified by a variety of studies. Many studies have suggested that there might be an association between attachment and mental health. In a different thread of research, studies provided evidence that dysfunctional emotion regulation has a potential impact on an individual‘s mental health. The present review has the purpose to examine available papers on the association of adult attachment with mental health with particular emphasis on the role of emotion regulation in this association. A database search was conducted for published data in Psych INFO, Elsevier and Google Scholar by combining search terms: ‗adult attachment‘, ‗mental health, diseases or illnesses‘ and ‗emotion regulation‘. A total of 182 studies were identified and screened, and finally 19 studies met inclusion criteria. Results of this review revealed a moderate association between insecure attachment and several mental disorders. Also, individuals with insecure attachment showed more difficulty in emotion regulation. However, some studies found no positive association between avoidant attachment and mental disease. This review suggests that individuals with insecure attachment show an increased risk for mental disorders and that and emotion dysregulation might mediate this relationship. However, most of studies had non-clinical samples which could affect result. Therefore, further research is needed to examine clinical samples regarding the attachment in adulthood and mental health and the role of emotion regulation to come up with more accurate results in the future.

Keywords: insecure attachment, attachment style, emotion regulation, mental health

The role of emotion regulation in the association of adult attachment and mental health: A systematic review

1. Introduction Meer et al., 2015; Mikulincer & Florian, 1998; Shakory et al., 2015). Mental health in adulthood might be affected by several causes such as genetics Several studies investigate the hypothesis (Button et al. 2008; Lau and Eley 2008), that emotion regulation is at least partly drugs and alcohol (Newton-Howes and responsible for the link between adult Boden, 2015), physical and sexual abuse attachment style and mental health. (Cutajar et al., 2010; Mueser et al., 1998; However, there is so far no literature review Mueser, Salyers, et al., 2004), exposure to available on this association. Therefore, this disasters such as flood or earthquake comprehensive review provides an (Norris et al., 2002) and violence overview of the literature of the relationship (Follingstad 2009; Golding 1999). between attachment and mental health in Although mental illness has been linked adulthood, considering the role of emotion with abundant risk factors, attachment and regulation to supply a wide range of emotion regulation seem to be very suggestions for future research. This review important components in the development begins with a description of theory of of mental disorders (Ponizovsky et al., attachment and explanation of its 2007; Nolen-Hoeksema & Aldao 2011). categories. Then, a concept of the Given the importance of attachment and its relationship between emotion regulation, trace during life period, many studies have attachment and mental health will be investigated the relationship between examined. Subsequently, this paper reviews attachment and mental health and detected a the empirical papers to examine the relation strong association between those (Banford between attachment, emotion regulation et al., 2015; Gajwani et al., 2013; Roberts et and mental disorder in adulthood. At the al., 1996; Wei et al., 2003, 2004, 2006., end, we provide a conclusion of the Kobak, Sudler, and Gamble, 1991). Strong reviewed papers. evidence shows that individuals with anxious or avoidant attachments face a 1.1. Adult attachment and dimensions higher risk of mental health problems (Besser & Neria, 2010, 2012; Elwood & Attachment theory (Bowlby, 1969; Williams, 2007). Ainsworth and Bowlby, 1991), which started with a focus on infant-mother In a different thread of research, there is attachment, has developed about 20 years growing evidence that emotion since its beginnings to also focusing on dysregulation such as anger and sadness to adult functioning (Hazen and Shaver, emotional and behavioral problems are 1987). Bowlby explained attachment theory linked to increased vulnerability to as ‗a way of conceptualizing the propensity developing mental disorders (Gilbert, et al., of human beings to make strong affectional 2011; Gilbert et al., 2012; Eisenberg, bonds to particular others and of explaining Cumberland, et al., 2001; Storch et al., the many forms of emotional distress and 2011; Silk, Steinberg, & Morris, 2003; personality disturbance, including anxiety, Clyne et al., 2010). Also emotion regulation anger, depression, and emotional showed a substantial association with detachment, to which unwilling separation attachment as plenty of studies have and loss give rise‘ (Bowlby, 1979, p. 127). demonstrated (Bost et al,. 2014; Van der

Studies have shown that the type of different attachment orientations have attachment style during childhood becomes different internal working models of the self relatively stable in adulthood (Hazen and and of others. Interaction with the Shaver, 1990; Fraley, 2002). The caregivers who are supportive in times of dimensions of attachment style are demand, bring up the development of described by using three terms: secure, attachment security (Sroufe and Waters, anxious and avoidant attachments (George, 1997). As a result, positive internal working Kaplan, and Main, 1987; Hazan and Shaver models build a foundation for proper mental 1987; Brennan, Clark, & Shaver, 1998). health (Mikulincer & Shaver, 2003). These dimensions are also suggested in a Nevertheless, when individuals develop four-category model of adult attachments negative representations of themselves or (Bartholomew and Horowitz, 1991). others through uncertain parental support, Generally speaking, anxious attachment is they become more vulnerable to characterized by worriedness of availability psychopathology. A negative internal of people and motivates to achieve attention working model of self derives from and love from a partner or close person to inconsistent care and attention from overcome distress. A person with avoidant caregivers, and leads to attachment anxiety. attachment strives to rely on himself and Individuals with avoidant attachment have a would not inquire help even though he negative internal working model of others, needed. Securely attached adults, however, because they did not receive sufficient demonstrate low anxiety and low avoidance response from their caregiver (Mikulincer and are comfortable to trust other people, et al., 2003; Pietromonaco and Feldman thereby developing an intimate long-term Barrett, 2000). Therefore, anxiously relationship. (Bowlby, 1969; Shaver and attached individuals seek proximity to an Fraley, 2008; Mikulincer and Shaver, excessive extent, they experience distress 2003). Meanwhile, Bartholomew and when they find people unavailable and they Horowitz (1991) illuminated four aspects of encounter with fear of abandonment. While attachment as: preoccupied, dismissing- avoidantly attached individuals feel uneasy avoidant, fearful-avoidant and secure being close to others, they attempt to attachment which have been used in various become self-reliant and they minimize researches. Preoccupied attachment is emotional displays (Brennan et al., 1998). specified by high anxiety and low A growing body of research investigating avoidance, dismissing-avoidant attachment the association of attachment and mental with high avoidance and low anxiety, and disorder (Ponizovsky et al., 2007; West & fearful-avoidant attachment by high anxiety George, 2002; Bartholomew and Horowitz, and high avoidance. However, securely 1991; Brennan, et al., 1998; Hazan and attached individuals show both low anxiety Shaver, 1987; Allen et al., 2001; Bifulco et and low avoidance. al., 2002) found that individuals with secure attachment represented higher 1.2. Attachment and mental health psychological functioning, while individuals with insecure patterns of The explanation of attachment theory will attachment style experience more mental provide a path to understanding the illness symptoms. development of secure attachment, that it may assist people to overcome distress and 1.3. Attachment and emotion regulation restore confidence and emotional balance (Cassidy & Shaver, 2016). Bowlby (1973, Attachment theory (Bowlby, 1973, 1980, 1980) explained that individuals with 1982) is a useful and influential framework

Copyright © 2018, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Mortazavizadeh Z. et al. Archives of Psychology, vol. 2, issue 9, September 2018 Page 4 of 25 for understanding emotion regulation across support security (Mikulincer & Shaver, the lifespan (Mikulincer, Shaver & Pereg, 2008). 2003). Following Bowlby (1980), modern attachment theorists (Cassidy & Berlin, 1.4. Emotion regulation and mental 1994; Thompson, 2013; Cassidy & Kobak, disorder 1988) recently discovered the maintaining role of emotion regulation in relationship Emotion regulation (ER) develops with attachment figures. Also, Sroufe throughout the lifespan (Cole, 2014). The (1996) expressed that attachment can be impact of emotion regulation on mental described in terms of dyadic regulation of health has recently become a substantial emotion regulation. theme in many investigations (Aldao et al., 2010; Gross & Thompson, 2007; Koole, The development of attachment style in 2009; Kring & Sloan, 2009). Yet, the individuals derives from the basic concept of emotion regulation has been attachment experience with their caregiver. found in several definitions and there is a Two dimensions of insecure attachment lack of universal definition for emotion (Brennan et al., 1998) will appear across regulation (Cole et al., 2004). According to childhood and adulthood as attachment Gross (1998) emotion regulation is ―the avoidance and attachment anxiety. High process by which individuals influence attachment anxiety will lead to which emotions they have, when they have desperateness and make individuals them and how they experience and express uncertain about their ability to handle these emotions‖ (p. 275). However, distress without the attachment figure‘s Campos et al. (2004) suggested that assistance (Mikulincer et al., 2003). emotions can simultaneously occur with the Anxious attachment would be associated regulation of the same emotion. Therefore, with a heightening of negative emotions several definitions became apparent for whereas these individuals learned that a emotion regulation. With regards to heightening of negative emotions would be regulation of emotion, two categories of ER essential to draw attention from others can be distinguished, adaptive and (Cassidy, 1994). Nonetheless, individuals maladaptive emotion regulation. Problem with an avoidant attachment style prefer to solving and reappraisal of positive or have emotional distance; therefore, they neutral interpretations of events are rarely possess comfortable feelings about examples of adaptive emotion regulation others. Also, avoidant individuals rely upon (Aldao et al., 2010). Suppression and deactivating strategies which lead to avoidance are examples of maladaptive suppression of negative emotions and emotion regulation (Gross, 1998; Hayes et cognitions and distance from the attachment al., 2004). Gross and John (2003) context. Subsequently, a long term of categorized ER into two categories of hyper-activation and deactivation may strategies: antecedent-focused strategy and make individuals vulnerable to pervasive response-focused strategy. According to emotional problems (Mikulincer et al., this model, an antecedent-focused strategy 2003). In contrast, a secure attachment occurs early and thereby intervenes before individual facing threat engages in the emotional response tendencies have proximity-seeking behaviors in order to be been fully generated. Maladaptive emotion close to an attachment figure. Hence, a regulation, which is described as response- raised adaptive mechanism of emotion focused strategy (Gross and John, 2003), regulation relieves distress and continues to would reduce the behavioral expression of negative emotion, and occur after the

Copyright © 2018, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Mortazavizadeh Z. et al. Archives of Psychology, vol. 2, issue 9, September 2018 Page 5 of 25 generation of the emotional responses. combining the key terms: ‗adult Although both emotion regulation strategies attachment‘, ‗mental health, diseases or could have positive and negative illnesses‘ and ‗emotion regulation‘. Further consequences, maladaptive ER is suggested criteria of eligible papers were English as being associated with a wide range of language, adulthood and published in peer mental disorders (Gross & Munoz, 1995; reviewed journals. Subsequently, the Moore et al., 2008; Aldao et al., 2010). reference lists of relevant papers were Additionally, Baradly (2000) has noted that examined to identify additional suitable maladaptive ER may precede the papers. The term ―emotional disclosure‖ as development of psychopathology. Indeed, a an aspect of emotion regulation was also deficit of emotion regulation is a common used in the search to bring up more study problem in abundant psychiatric disorders results. (Berking and Wupperman 2012). Therefore, emotion regulation has been proposed as a Assuming these criteria, 182 studies were robust predictor of mental health identified, of which 56 were duplicates and functioning (Nolen-Hoeksema and Aldao removed. Afterwards, 111 studies were 2011). Additionally, as Gross and Levenson excluded according to the following criteria (1997) explained, psychiatric disorders (see figure 1): might be conceptualized as difficulties with  Did not assess all criteria emotion regulation. ‗attachment, emotion regulation and mental disorder‘ together 2. Method of the review  Using participants under 18 years of age To find pertinent publications on the topic  Not published in a peer reviewed of attachment and mental health in journal adulthood which includes emotion  Not written in English regulation as a mechanism, a database search has been conducted. The search was Finally, 19 qualified studies were identified conducted in the electronic databases Psych for inclusion in this paper. INFO, Elsevier and Google Scholar by

Figure 1. PRISMA flow chart.

3. Results account the role of emotion regulation. It describes details of sample, measurement, Table 1 summarizes the 19 identified studies and results. Subsequently, we synthesize the and their key results on the link between findings for different categories of mental attachment and mental health, taking into health outcomes.

Table 1. Summary of relationships found between attachment and mental health and role of emotion regulation in the studies included in this review

Title /Author Sample Attachment Emotion Mental health Key results measure regulation measure measure Depression and anxiety disorder Adult Attachment, 284 college Relationship Difficulties in Beck Depression Insecure attachment Emotion Dysregulation, undergraduates, M Scales Emotion Inventory, Second styles associated with and Symptoms of age=20.5, Questionnaire. Regulation Edition (BDI-II; emotion dysregulation Depression and (RSQ; Scale (DERS; Beck, Steer, & and with symptoms of Generalized Anxiety SD=4.8; 230 Griffin & Gratz & Ro- Brown, 1996) both depression and Disorder. Marganska et women and 54 men Bartholomew, emer, 2004) GAD al. (2013) 1994) Adult attachment style 147 participants Experiences in Difficulties in Beck Anxiety The association and anxiety – The Close Emotion Inventory (BAI; between mediating role of emotion 110 women Relationships- Regulation Beck et al., 1988) Anxiety and attachment regulation. Nielsen et al. Revised (ECR- Scale (DERS; anxiety mediated by (2017) R; Fraley et al. Gratz & emotion regulation. M &SD= not 2000). Roemer, 2004). Avoidant attachment recorded was not related to anxiety.

Depressive affect among 198 patients Adult Emotional VROPSOM (van Anxious attachment health care seekers: How Attachment Disclosure Rooijen, 1979), the was correlated with it is related to attachment Mean age=42; Scale (Collins Questionnaires Dutch adaptation depressive affect and style, emotional SD=15.02 & Read, 1990). (Stroebe et al., of the Depression disclosure, while disclosure, and health 2002). Adjective avoidance attachment complaints. Zech et al. Checklist (Lubin, was not related to 124 women, (2006) 1965). disclosure and 71 men (3 undisclosed depressive affect. Disentangling the effects 121 college Experiences in Distress Inventory of Depression symptoms of depression symptoms students Mean Close Disclosure Depression and were negatively related and adult attachment on age=19.76, Relationships Index (DDI, Anxiety to emotion disclosure emotional disclosure. SD=3.48; 96 Scale (ECRS; Kahn and Symptoms (IDAS; tendencies. Attachment Garrison et al. (2012) women,25 men Brennan et al., Hessling, 2001). Watson et al., avoidance was 1998). 2007). negatively related to disclosure. Attachment anxiety and intra- individual disclosure positively related. Distress and adult Psychopathology Mindfulness and the 402 undergraduate Experiences in Difficulties in Depression Distress correlated with Experience of students. Close Emotion Anxiety Stress attachment anxiety and Psychological Distress: Relationships- Regulation Scales-21 (DASS- emotion dysregulation. the Mediating Effects of M,SD= not Revised (ECR- Scale (DERS; 21; Lovibond and Attachment avoidance Emotion Regulation and reported 68 men, R) (Fraley et al. Gratz and Lovibond, 1995). was not significantly Attachment Anxiety. 334 women 2000). Roemer, 2004). correlated with the McDonald et al. (2016) distress.

Do Attachment Style and 98 participants at Experiences in Cognitive Brief Symptom Attachment anxiety Emotion Regulation 50 % risk for HD, Emotion Inventory (BSI; De associated with Strategies Indicate CADASIL, or Close Regulation Beurs and Zitman distress. Attachment

Distress in Predictive HCHWA-D Relationships- Questionnaire 2005; Derogatis avoidance and Testing? Van der Meer et Revised (ECR- (CERQ; 1975). maladaptive emotion al (2015) Mean age=37.3 R; Fraley et al. Garnefski et al. regulation strategies years, SD=12.3; 48 2000). 2001). did not contribute to men, 50women the strong association of pretest distress with distress after predictive testing. Preventive Resources and 390 students Parental Negative Mood Hopkins Symptom Result showed an Emotion Regulation Attachment Regulation Checklist (HSC; association of insecure Expectancies as Mean age=21.04, Questionnaire Scale (NMRS; Greene et al., attachment with Stress Mediators Between (PAQ; Kenny, Catanzaro and 1988). symptoms and Attachment and College 1987, 1990). Mearns, 1990). Stress-produced SD =2.34; students‘ Stress Inventory of emotions and also Outcomes. McCarthy et Parental and emotion regulation. al. (2006) 68.4% women, Peer 31.6% men Attachment (IPPA; Armsden and Greenberg, 1987, 1989). Maternal Attachment 277 adolescent and Experiences in Difficulties in Coping with Difficulties with Style and Responses to their mothers. Close Emotion Children‘s emotion regulation Adolescents‘ Negative M,(SD) mothers= Relationships Regulation Negative Emotions mediated the link Emotions: The Mediating Time 3, Time 4, Scale (ECR; Scale (DERS; Scale – Adolescent between maternal Role of Maternal Time 5= 44.09 Brennan et al., Gratz & Version (CCNES- attachment style and Emotion Regulation. (6.07) 45.13 (6.08) 1998). Roemer, 2004). A; Fabes & responses to Jones et al. 46.65 (6.19); Eisenberg, 1998). adolescents‘ negative (2014) emotions. Adolescents= 13.06 (0.89) 14.02 (0.90) 15.04 (0.95). Attachment and Emotion 50 young adults Inventory of Emotional Symptom Attachment insecurity Regulation Strategies in from 14 till 24 ; Parent and Peer Expressivity Checklist 90– to parents in Predicting Adult Mean age = 23.5, Attachment Scale (EES). Revised (SCL-90- adolescence associated Psychopathology. SD = .88 (IPPA; Kring et al., R, (Derogatis, with symptoms of Pascuzzo et al. (2015) (Armsden & 1994). 1983). Coping psychopathology in 33 women and 17 Greenberg, Inventory for adulthood. Emotion- men 1987). Stressful focused strategies fully Experiences in Situations (CISS; mediated the positive Close Endler & Parker, association between Relationships 1994). anxious attachment in (ECR; Brennan young adulthood and et al., 1998). adult psychopathology. Well being Attachment and well- 632 participants Attachment Emotion Dutch version of Each attachment style being: The mediating role Styles Regulation the Resilience was associated with a of emotion regulation and Mean age= 36.92, Questionnaire Questionnaire Scale (RS–nl, unique pattern of resilience. Karreman & SD = 13.06; 305 (van (ERQ; Gross & Portzky et al. emotion regulation and Vingerhoets (2012) men, 327 women Oudenhoven, John, 2003; 2010; original RS, resilience. All Hofstra, & Dutch Wagnild & Young, attachment styles had Bakker, 2003). translation 1993). Dutch indirect effects on well- Koole, 2004). version of the being through WHO-Five well- reappraisal and being index resilience. (WHO, 1999).

Borderline and somatoform disorder Adult attachment and 472 participants Dutch version Dutch The Composite Insecure attachment emotion dysregulation in of Relationship questionnaire, International associated with PBD borderline personality and with BPD only, Style Bermond Vorst Diagnostic and SOD by somatoform disorders. SoD only, BPD Questionnaire Alexithymia Interview (CIDI; peractivating emotion Dijke et al. (2015) with co-morbid (RSQ; Griffin& Questionnaire Andrews G, Peters dysregulation in BPD SoD, Mean Bartholomew, (BVAQ;Vorst L, 1997, Dutch and deactivating age=34.7, 1994). HCM, Bermond version, Ter emotion dysregulation SD=10.1, B, 2001). Dutch Smitten, Smeets, in SoD. version of the & Van den Brink). 145men,327women Structured Interview for The Borderline Disorders of Personality Extreme Stress Disorder Severity Not Otherwise Index Specified, (BPDSI; Dutch Revised version, Arntz A., (SIDES; Ford & 1999). kidd, 1998). The Mediating Role of 354 adults Attachment Difficulties in Borderline Childhood abuse and Emotion Dysregulation in Style Emotion Personality adult attachment were the Relations Between Mean age=34.70, Questionnaire Regulation Inventory (BPI). associated with Childhood Trauma (ASQ; Feeney, Scale (DERS; The BPI (Chabrol emotion dysregulation History and Adult Noller, & Gratz & et al., and borderline SD = 15.22 years Attachment and Hanrahan, Roemer, 2004;Leichsenring, personality features. Borderline Personality 1994). 2004). 1999a). Emotion dysregulation Disorder Features: A 251 women mediated the relevance Study of Italian Childhood Abuse of emotional abuse and Nonclinical Participants. 180 men and Trauma Scale fearful/occupied Fossati et al. (2016) (CATS; Sanders & attachment and Becker- borderline personality Lausen, 1995). feature. Eating disorder College Student Binge 381 undergraduate Experiences in Emotion Binge Eating Scale Insecure attachment Eating: Insecure & graduate Close Regulation (BES; Gormally, and binge eating were Attachment and Emotion students Relationship Scale (DERS; Black, Daston, & related and the insecure Regulation. Han and Short Form Gratz & Rardin, 1982). attachment–binge Pistole (2014) Mean age =25.2, (ECR-S; Wei, Roemer, 2004). eating association was Russell, fully mediated by Mallinckrodt, & emotion regulation. SD = 6.06; 155 Vogel, 2007). men ,221 women Binge eating in bariatric 1388 morbidly The Difficulties in The Eating Difficulty with emotion surgery candidates: The obese patients Experiences in Emotion Disorder regulation mediated the role of insecure Close Regulation Examination relationship between attachment and emotion Mean age=44.69, Relationships Scale (DERS; Questionnaire both avoidant and regulation. Shakory et al. scale (ECR- Gratz & (EDE-Q 6.0; anxious attachment (2015) M16; Lo et al., Roemer, 2004). Fairburn & Beglin, styles and binge eating. SD = 10.59 2009). 1994). Women =79.3% Insecure Attachment and 247 participants Relationships— Difficulties in Eating Attitudes Avoidant and anxious Disordered Eating in Relationship Emotion Test (EAT-26; attachment styles women: The Mediating Mean age= 24.51, Structures Regulation Garner, Olmsted, predicted the level of Processes of Social SD = 4.05 (ECR-RS; Scale (DERS; Bohr & Garfinkel, disordered eating Comparison and Emotion Fraley, Gratz & 1982). symptoms. Emotion Dysregulation. Ty & Heffernan, Roemer, 2004). dysregulation and

Francis. (2013) 247 women, Vicary, & social comparison Brumbaugh, tendencies mediated 0 men 2011). relation between insecure attachment and eating pathology. Child abuse Attachment Organization, 109 participants Adult General Child Author suggested Emotion Regulation, and Attachment Expectancy for Maltreatment available relationship Expectations of Support Mean age= 35.61, Interview (AAI; Negative Mood Interview Schedule between insecure in a Clinical Sample of SD = 10.79 George et al., Regulation (CMI; Briere, attachment and Women With Childhood 1996). scale (NMR; 1992). psychiatric outcomes. Abuse Histories. Cloitre Catanzaro & Also, emotion 109 women, et al. (2008) Mearns, 1990), regulating plays a role in this relationship. 0 men Child maltreatment types 361 undergraduate Experiences in Difficulties in Crime and Types of child and risk behaviors: students Close Emotion Analogous maltreatment were Associations with Relationships- Regulation Behavior related to anxious and attachment style and Mean age=19.1, Revised (ECR- Scale (DERS; (CAB scale; Miller avoidant attachment emotion regulation R; Fraley et al. Gratz & & Lynam, 2003). styles, emotion dimensions. Oshri et al. 2000). Roemer, 2004). dysregulation, and a SD = 1.7; 225 (2015) variety of risk women, 135 men, 1 unknown behaviors. Dementia disorder Attachment style and 168 participants Attachment Feelings and BEHAVE-AD Attachment styles emotion regulation in diagnosed as Style Emotions (Reisberg et al., designations were dementia patients and having dementia Questionnaire Inventory 1987). related to patterns of their relation to caregiver with their (Hazan & (FEI). emotion regulation. burden. Magai and Cohen caregivers. Shaver, 1987). Attachment style was (1998) related to the pattern of Mean behavioral symptoms age=76.3years, displayed by dementia patients, and to caregiver burden. SD=7.3; 80%women Posttraumatic stress disorder Emotion regulation 36 participants AAP interview Emotional Coping Inventory Higher level of strategies as mediators of (George, West, Expressivity for Stressful attachment security the association between Mean age= 33, & Pettem, Scale (EES) Situations (CISS; was associated with level of attachment SD=9.28 1997). (Kring, Smith, Endler & Parker, fewer PTSD symptoms security and PTSD & Neale, 1994). 1994). post trauma. Emotion symptoms following regulation mediated the 16 women, 20 men trauma in adulthood. association between Benoit et al. (2010) attachment and PTSD symptoms.

3.1. Depression and anxiety disorders participants diagnosed with anxiety disorders. Results of this study revealed an Recently, Nielsen et al. (2017) investigated association between anxiety and attachment the relationship between adult attachment anxiety (b=4.60, p < .0001). Also, emotion style and anxiety disorders and the dysregulation was significantly related to mediating role of emotion regulation in a attachment anxiety (b=10.30, p < .0001) sample of 147 participants with 90 and anxiety symptoms (b= 1.06, p < .0001).

However, when using attachment anxiety in Individuals with anxious attachment the mediation model, avoidant attachment showed more depressive affect (b= .30, p < was not correlated with anxiety or emotion .001) and they disclose their emotion (r= regulation. .31). In contrast, avoidant attachment was negatively related to depressive affect In a study of 18-48 years old adults, (b=0.35, p < .001) and the patients also Marganska et al. (2013) reported a vice displayed less emotional disclosure (r= – versa correlation between secure .22). Nonetheless they had greater physical attachment, emotion dysregulation and problems. symptoms of generalized anxiety disorder and depression. Preoccupied and fearful avoidant attachment presented a significant 3.2. Distress and adult psychopathology association with depression (b =.31, and McDonald et al. (2016) examined the .25, respectively, p < .01) and generalized relation between psychological disorder and anxiety disorder (b= .25, and .18, mindfulness taking into account the role of respectively, p < .01). This study indicated attachment and emotion regulation in a that emotion dysregulation was positively community sample of 17-24 year-old related to insecure attachment and also adults. In this study, psychological distress mediated the relation between attachment had a positive correlation with emotion style and depression and anxiety disorder. regulation and attachment anxiety. A Garrison et al. (2012) investigated adult bootstrap confidence interval (BCI) attachment and depression symptoms as a revealed that emotion dysregulation and predictor of individual‘s emotional attachment anxiety were significant disclosure in a community sample of 121 mediators of the relationship between college students. Emotional disclosure as a mindfulness and stress (95% BCI −1.70 to means of emotion regulation in this paper is −0.99; 95% BCI −0.51 to −0.12). However, defined as sharing information about one‘s attachment avoidance did not show a emotional experiences. Individuals with significant relation to psychological distress higher level of depression symptoms and mindfulness, but was correlated with reported weaker emotional disclosure dysfunctional emotion regulation. Also, during their engagement in emotional they found a strong indirect effect of events. This finding shows that depression dysfunctional emotion regulation in symptoms are relevant to emotional comparison with attachment anxiety when disclosure. They also found a negative they measured distress. association between attachment avoidance In addition, more recently, Van der Meer et and both generalized disclosure tendencies al. (2015) investigated a community sample and daily emotional disclosure (b= −.14 and of 98 adults with 50% risk in neurogenic −.04, p < .05). Attachment anxiety, on the disorder such as Huntington‘s disease, to other hand, indicated a moderation role detect whether an insecure attachment style between daily event intensity and disclosure and emotion regulation is associated with relation (b= .12, p < .05). distress before and after predictive testing. In another study concerning emotional They found that attachment anxiety and disclosure and mental disease, Zech et al. level of distress were associated before the (2006) investigated depressive affect in 198 test (b=0.239, p=0.03). Also, research has patients visiting a general practitioner (GP) shown that attachment anxiety displayed to find whether it is related to attachment, distress up to 2 months after testing. In emotional disclosure and health complaints. contrast, attachment avoidance was not

Copyright © 2018, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Mortazavizadeh Z. et al. Archives of Psychology, vol. 2, issue 9, September 2018 Page 12 of 25 associated before and after test. Besides strategies in a 10-year longitudinal design this, the results reported that maladaptive on adult symptoms of psychopathology emotion regulation did not have an effect which included 33 young women and 17 after predictive testing. young men. In this study, participants filled in various questionnaires, such as Similarly, McCarthy et al. (2006) found attachment security to peers and parents, support for the mediating role of emotion emotion regulation and self-reported regulation expectancies and preventive symptoms of psychopathology in different coping recourse between attachment and ages. Adolescents who reported higher stress outcomes (stress symptoms and stress attachment insecurity to their parents produced emotion). Also, parental showed greater symptoms of attachment was associated with stress psychopathology in their adulthood (b=.64, symptoms and stress-produced emotions p < .01) and this relationship was partially (r= −.45 and −.56). The authors suggested mediated by emotion-focused strategies. that mood-regulation expectancies in Moreover, the association between anxious stressful situations need both sufficient romantic attachment in young adulthood preventive coping resources and an and adult psychopathology was fully attachment background. mediated by emotion-focused strategies. Jones et al. (2014) conducted a longitudinal study in a sample of 227 adolescents and 3.3. Well-being their parents. They examined the relation between mother‘s attachment and their Karreman and Vingerhoets (2012) also response to their adolescent‘s negative investigated the association between emotions and also whether emotion attachment and well-being by considering regulation could mediate this relation. the role of emotion regulation and resilience Negative emotions included: distress as mediators amongst 632 individuals 16-67 responses (e.g., becoming anxious), harsh years old. While secure and dismissing responses (e.g., invalidating emotion) and attachment was associated with high well- supportive responses (e.g., helping to solve being (b = 8.57, p < .001 and b = 3.77, p < the problem). Mothers with avoidance .01), preoccupied attachment negatively attachment (b = .20, p < .05) or anxiety predicted well-being (b = −4.75, p < .001). attachment (b = .47, SE = .14, p < .01) However, fearful attachment was not exhibited more difficulty with emotion associated with well-being and suppression regulation. Also, emotion dysregulation was could not mediate the relation between positively correlated to mothers‘ distress attachment and well-being. The results responses to their adolescents‘ negative showed that all types of attachment styles emotions (b = .53, p < .01). Mothers were affected well-being through the reappraisal more likely to endorse distress and harsh dimension of emotion regulation and responses, and they displayed greater resilience. difficulties with emotion regulation. The authors suggested that difficulties with 3.4. Borderline and somatoform disorder emotion regulation mediated the relation between maternal attachment style and Van Dijke and Ford (2015) examined response to adolescents‘ negative emotions. attachment and emotion dysregulation in a community sample of 472 patients with In another longitudinal study, Pascuzzo et borderline personality disorder (BPD), al. (2015) investigated the role of somatoform disorder (SoD) or another attachment and emotion regulation psychiatric disorder. Results showed that

Copyright © 2018, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Mortazavizadeh Z. et al. Archives of Psychology, vol. 2, issue 9, September 2018 Page 13 of 25 under-regulation was associated to binge eating who are bariatric surgery attachment anxiety, namely fear of candidates. Results revealed a positive abandonment (r = 0.30, p < 0.001). correlation between anxiety attachment and However, over-regulation correlated with binge eating (b = 0.02, t=6.36, p = .001). attachment avoidance, namely fear of However, avoidance attachment was not closeness (r = 0.44, p < 0.001). associated with binge eating unless Furthermore, BPD was associated with difficulties with emotion regulation under-regulation of affect and fear of controlled as a mediator, in which case a abandonment. The SoD group tended to significant association appeared (b = −0.10, over-regulate and was associated with fears p = .006). Moreover, difficulty of emotion of abandonment or closeness. Also, Fossati regulation mediated the relationship et al. (2016) recently provided an between attachment avoidance/anxious and investigation among 354 non-clinical adults binge eating. and evaluated the mediation role of emotion regulation in the relationship between child In a further study, Ty and Francis. (2013) trauma history, adult attachment and BPD. also examined disordered eating and Results showed that childhood (emotional) insecure attachment in women by abuse and adult attachment were positively considering the mediation role of emotion associated with emotion dysregulation and regulation and social comparison. This BPD features (r = .41, p < .001). BPD research identified a positive and significant features were associated with both association between anxious and avoidant preoccupied/fearful and anxious/ambivalent attachment and eating disorder symptoms insecure attachment. However, only and also with emotion dysregulation. preoccupied/fearful attachment was However, attachment anxiety towards associated with both emotion dysregulation partner showed the strongest correlation and BPD features. Furthermore, emotion with eating disorder (r = .34, p < .001). dysregulation significantly moderated the relationship between both emotional abuse 3.6. Child abuse and fearful/preoccupied attachment and BPD features. In a clinical sample of 109 women with childhood abuse histories, Cloitre et al. (2008) identified a correlation between 3.5. Eating disorder insecure attachment and psychiatric Han and Pistole (2014) investigated outcomes, and insecure participants showed emotion regulation as a mediator of more problematic functions compared to attachment insecurity and binge eating in a secure participants (b=.25, p <.05), with sample of 381 students who were recruited emotion regulation playing a role in this in an online survey. Insecure attachment relationship (b=.09, p <.05). Nonetheless, and binge eating were positively correlated the author could not detect results for the (b = .37, p < .001). The results also provide dismissing group due to the small number evidence for a full mediating role of of participants in this category. emotion regulation for the insecure One study, which included 361 attachment and binge eating association. undergraduate students, investigated Additionally, in other research regarding attachment style and emotion regulation in binge eating, Shakory et al., (2015) relation to child maltreatment and types of examined binge eating and the role of risk behaviors (Oshri et al., 2015). The insecure attachment and emotion regulation authors found that variables such as among 1388 morbidly obese patients with

Copyright © 2018, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Mortazavizadeh Z. et al. Archives of Psychology, vol. 2, issue 9, September 2018 Page 14 of 25 emotional abuse were associated with less to utilize emotion-focused strategies to anxious (b = .30, p = .001) and avoidant (b cope with traumatic experiences (r= –.47, = .15, p = .010) attachment. Also sexual p= .004). Moreover, emotion-focused abuse alternatively was related to anxious strategies and substance use - two (b = .11, p = .013) and avoidant attachment dimensions of emotion regulation examined (b = .19, p = .001). They were also related in the study - mediated the association to abundant risk behaviors and emotion between attachment and PTSD symptoms. dysregulation. This study demonstrated a different association in various types of abuse. Verbal abuse, for instance, was not 4. Discussion related to any dimension of emotion regulation or attachment styles (Oshri et al., 4.1. Attachment, Emotion regulation and 2015). mental disorders In this literature review, a moderate 3.7. Dementia disorder association between attachment style and mental disorders emerged. Additionally, Magai and Cohen (1998) conducted a study regarding the potential role of emotion measuring attachment and emotion regulation, individuals with insecure regulation in elderly dementia patients and attachment had more difficulties in emotion their relation to caregiver burden. Results regulation; therefore, the group with showed that the burden for caregivers who insecure attachment and emotion care for an individual with avoidant and dysregulation showed an increased risk for ambivalent premorbid attachment was mental disorders. higher than those with secure premorbid attachment (t = –3.54, p < .02, t = 3.51, p < In spite of the results demonstrating the .001). This study showed that avoidant relation between insecure attachment and premorbid attachment style was also mental illness, some insight into avoidant associated with premorbid emotions of attachment examined in several studies anger, contempt and reserve and in contrast provided different results that need to be with secure individuals; they had greater discussed. Although most studies reviewed levels of disturbance and paranoid in this paper showed an association between delusions. Ambivalent premorbid emotion regulation, attachment and mental attachment, on the other hand, was health, in some studies emotion regulation associated with premorbid emotions of failed to be a mediator of this relationship. sadness and was related to higher levels of For example, Shakory et al. (2015) found anxiety and depression. no positive association between avoidant attachment and binge eating. It should be 3.8. Posttraumatic stress disorder noted, however, that individuals with avoidant attachment downregulate their Benoit et al. (2010) investigated emotion emotions with suppression and denial of regulation as a mediator between negative emotions (Tasca & Balfour, 2014; attachment and Posttraumatic stress Shaver et al., 2008). In addition, in a more disorder (PTSD) symptoms in a sample of recent study, Nielsen et al. (2017) found no 33 adults. The finding showed that relation between avoidant attachment and attachment security was negatively both anxiety disorder and emotion associated with all dimensions of PTSD regulation, while it was covariant with symptoms at 12 weeks post trauma. Also, attachment anxiety. Also, Van der Meer et individuals with secure attachment tended al. (2015) and McDonald et al. (2016)

Copyright © 2018, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Mortazavizadeh Z. et al. Archives of Psychology, vol. 2, issue 9, September 2018 Page 15 of 25 found that there was no correlation between growing independency in avoidant avoidant attachment and psychological individuals, they would not accept negative distress. Similarly, Karreman and feelings. Moreover, to suppress affective Vingerhoets (2012) found no direct reactions, individuals with avoidant correlation between fearful attachment and attachment utilize defensive strategies well-being when controlling for other (Mikulincer & Orbach, 1995). attachment styles scores. Moreover, although in this study suppression of In another study examining attachment emotion expression was associated with style with anxiety and depression disorders, attachment and well-being, it failed to avoidant (dismissive) attachment was mediate this link. associated only with depression whereas fearful avoidant and preoccupied Mikulincer and Shaver (2007) suggested attachment predicted both depression and that individuals with relatively high levels anxiety disorders (Marganska et al., 2013). of avoidant attachment may find it difficult To interpret this finding, both styles (fearful to express their thoughts and emotions, or avoidant and preoccupied) might be may not be aware of having problems, and characterized by hyper-activating emotion are known to under-report symptoms of regulation strategies that involve increased distress. Also, these authors believe that the monitoring of threats to the self, especially level of stress experienced by a non-clinical social threats such as abandonment. In sample might not be enough to activate the addition, the hyper-activating strategies typical pattern of responses associated with used by preoccupied and fearful individuals avoidant attachment. Moreover, individuals frequently involve attempts to elicit care with an avoidant attachment pattern tend to and attention from others, often through dismiss or downregulate distressing clinging behaviors (Mikulincer et al., 2003). emotions through emotional suppression or Meanwhile, Roberts et al. (1996) found that dissociation, and are less inclined to report individuals with higher level of avoidant distress. attachment reported more depressive symptoms that are associated with their With regard to gender aspects, the study of negative models of the self. Moreover, McDonald et al. (2016) is noteworthy since Magi and Cohen (1998) found that those it includes mainly women. For instance, it dementia patients who possess avoidant is possible that women are more inclined to attachment had fewer depression and report anxious, as opposed to avoidant anxiety disorders than individuals with attachment (Ainsworth et al. 1978). secure and anxious attachment. Furthermore, Garrison et al. (2011) claimed However, it should be noted that that avoidant attachment is negatively individuals with avoidant attachment are related to generalized disclosure tendencies believed to under-report their depressive and daily emotional disclosure. To explain symptoms (Dozier & Kobak, 1992). this, they assume individuals who are high Furthermore, Pascuzzo et al. (2015) also in avoidant attachment tend to suppress indicated no relation between avoidant their emotions and do not seek social romantic attachment orientation and the support when they are distressed global index of psychopathology, and (Mikulincer et al., 2003). Also, the findings emotion regulation (namely, emotion- of Zech et al. (2006) showed that avoidant focused strategy) partially mediated the attachment was not associated with emotion association between insecure parent- disclosure and depressive affect. However, adolescent attachment and adult symptoms the authors explained that while there is a

Copyright © 2018, Archives of Psychology. All rights reserved. http://www.archivesofpsychology.org Mortazavizadeh Z. et al. Archives of Psychology, vol. 2, issue 9, September 2018 Page 16 of 25 of psychopathology. Nevertheless, some an essential issue to provide variety of studies showed that under stress conditions knowledge in respect of the relationships avoidance might be related to the between the variables and ultimately to development of symptoms of come up with more accurate conclusions. psychopathology (Simpson & Rholes, Thus, additional studies are needed to 2004; Berant et al. 2001; Ein-Dor et al. examine clinical samples regarding the 2010). However, the low-risk sample in this attachment in adulthood and mental health research, as the author found, might be a and the role of emotion regulation in the reason to restrict the high-level stress by future. participants. Also, according to minimization of distress signal strategy in Additionally, sample size in some studies individuals with avoidant attachment, was not sufficient enough to be adequately under-reporting of symptom of powered. This is another reason why psychopathology might be feasible generalizing the results is problematic. It (Mikulincer & Shaver, 2007, 2008). would be an advantage for future investigations to provide an equal sample with both men and women and endeavor to 4.2. Conclusions and Future Directions encompass a large community sample as This review of existing papers on the well. association of attachment and mental health Self-report questionnaires are used in most with emotion regulation as a mediating of the reviewed papers. Self-report variable reveals some limitations that need measures are particularly vulnerable to the to be addressed by future investigations. In effects of social desirability and most papers in this review, a cross-sectional retrospective bias (Pervin, 1999). design was used, which presents a Therefore, future studies ought to utilize restriction with regard to the interpretation various measures like observation or of the study results. A cross-sectional interviews to assess psychopathology, design may be prone to non-response bias if attachment style, and emotion regulation to participants who consent to take part in the avoid this possible bias. Furthermore, study differ from those who do not papers in this review differ widely in the participate, resulting in a sample that is not applied measures of attachment, emotion representative of the population. However, regulation, and psychopathology. Hence, it is possible to record exposure to many consistency in the use of identical measures risk factors and to assess more than one in future studies would be beneficial. outcome in a cross-sectional study (Philip Sedgwick, 2014). Therefore, further Moreover, few studies have considered how research is recommended using longitudinal all attachment patterns are related to all and experimental designs to uncover causal dimensions of ER. Despite the lack of links in the relationship between adult research in these areas, however, more attachment, mental disorder and emotion insight is needed into how different aspects regulation with more detailed information. of ER and attachment are relevant to mental disorders in order to derive more conclusive The samples included non-clinical results. participants in most studies, which could affect results; furthermore, generalizing the results with non-clinical samples to clinical samples is not feasible. To clarify this, investigating clinical populations could be

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