A prospective investigation of the impact of attachment style on stress generation among clinically depressed individuals

Relationship Between Parental Attachment and Stress Elevation and Synchrony in Pediatric Occupational Therapy Patient-Parent Dyads

IMPORTANCE

Populations already experiencing chronic stress, such as families with children who are neurologically atypical, are at particular risk for developing stress-related disease.

OBJECTIVE

To establish feasibility of collecting salivary samples from pediatric occupational therapy patients and their parents in a clinical setting and at home and to examine associations among parental attachment style, parent self-reported stress, and physiological stress (i.e., cortisol) in pediatric occupational therapy patients who were neurologically atypical and their parents (N = 10 dyads).

DESIGN

Cross-sectional pilot study to test feasibility.

SETTING

Sliding-scale university clinic.

PARTICIPANTS

Participants were 10 children undergoing occupational therapy treatment and their parent. Families were approached and told the study was voluntary and would not affect their treatment. Families provided informed consent.

OUTCOMES AND MEASURES

Parents completed measures to assess their own attachment style, general and parenting stress, and stress in their child. Children and parents provided saliva samples during an occupational therapy clinic visit and collected samples at home to measure cortisol level.

RESULTS

Parent attachment avoidance was related to increased parent cortisol levels in the clinic and increased child cortisol levels at home. Parent and child cortisol levels had a strong, positive relationship in the clinic but not at home. We did not observe a difference between cortisol levels in children or parents in the clinic or at home.

CONCLUSIONS AND RELEVANCE

We concluded that this protocol is feasible and provide suggestions for future research.

WHAT THIS ARTICLE ADDS

Stress physiology in pediatric occupational therapy clients should be considered within the context of the family system. Family-based interventions may be particularly helpful for reducing client stress in this population.

Personality Factors and Attachment Styles as Predictors of the Therapeutic Efficacy of a Short-Term Ambulatory Intervention for Depression

BACKGROUND

Several studies have shown a significant positive impact of intensive short-term ambulatory psychiatric interventions for depression. However, data on outcomes related to factors that are predictive of the efficacy of these interventions in terms of remission or response to treatment remain scarce. The goal of this naturalistic prospective study was to identify factors, including Big Five Inventory personality traits and attachment style, that are predictive of the efficacy of crisis interventions (CIns) in major depressive disorder.

METHODS

The study included 234 adult outpatients with major depressive disorder who completed all assessments in a study of a short-term intensive ambulatory CIn. In this study, we evaluated sociodemographic factors, and scores on the Global Assessment of Functioning Scale, the Big Five Inventory personality assessment, the Montgomery-Åsberg Depression Rating Scale, and the Adult Attachment Scale.

RESULTS

Mean scores on the Montgomery-Åsberg Depression Rating Scale decreased significantly from 26.3 (SD=9.0) at admission to 10.6 (SD=8.1) at the end of the CIn (t=23.9; P<0.001); 99 patients (42%) experienced remission, 151 patients (65%) were considered treatment responders, and 98 patients (42%) both responded to treatment and experienced remission. Results of multivariate regression analysis showed that education level and family intervention were associated with response to treatment. Neuroticism traits were related to a lower rate of response to treatment. The dependency dimension attachment style had a positive impact on response to treatment.

CONCLUSIONS

Neuroticism traits can predict clinical outcomes after a short-term intensive psychiatric intervention for depression. Results of family interviews, education level, and Global Assessment of Functioning scores should also be taken into account in predicting clinical outcomes.

Childhood factors associated with increased risk for mood episode recurrences in bipolar disorder-A systematic review

BACKGROUND

Bipolar Disorder (BD) is a recurrent illness associated with high morbidity and mortality. The frequency of mood episode recurrence in BD is highly heterogeneous and significantly impacts the person's psychosocial functioning and well-being. Understanding the factors associated with mood recurrences could inform the prognosis and treatment. The objective of this review is to summarize the literature on factors, present during childhood, that influence recurrence.

METHODOLOGY

A systematic review of PubMed (1946-2017) and PsycINFO (1884-2017) databases was conducted to identify candidate studies. Search terms included bipolar disorder, episodes, predictors, recurrences, and course. Study characteristics, risk for bias, and factors associated with recurrence were coded by two raters according to predetermined criteria.

RESULTS

Twenty child studies and 28 adult studies that retrospectively evaluated childhood variables associated with mood recurrences were included. Early age of onset, low socioeconomic status, comorbid disorders, inter-episode subsyndromal mood symptoms, BD-I/II subtypes, presence of stressors, and family history of BD were associated with higher number of recurrences.

LIMITATIONS

Risk factors and mood recurrences were assessed and defined in different ways, limiting generalizability.

CONCLUSION

Multiple factors are associated with increased risk of mood episode recurrence in BD. Interventions targeting modifiable factors could reduce the impact of BD. For example, treatment of comorbid disorders and subsyndromal mood symptoms, coupled with appropriate cognitive behavioral and family-focused therapies could ameliorate risk related to many clinical factors. When coupled with social services to address environmental factors, the number of episodes could be reduced and the course of BD significantly improved.

Comparison of Team and Participant Ratings of Event Dependence: Inferential Style, Cognitive Style, and Stress Generation

Introduction: Previous research has linked negative cognitive styles with stress generation. However, measures of cognitive styles have replied on ratings for hypothetical events, not experienced events. We examined the relationship between stress generation and attributional style for experienced events (i.e., inferential style) at both macro and daily levels.

Methods: We measured stress generation in college students using the traditional objective team ratings (i.e., observer) as well as via participants’ own ratings (i.e., actor), which we argue captures more information and is consistent with calls for participant-centered research.

Results: Cognitive style and inferential style positively correlated, indicating consistency between these two forms of assessment. Actor and observer identified events were significantly correlated for both dependent and independent events, suggesting that participants and teams are consistent in these categorizations. Results from both studies showed that inferential style was associated with actor but not observer identified dependent events.

Discussion: Our findings provide some of the first evidence for the role of inferential style in actor identified stress generation and indicate that it is useful to examine both participant and observer ratings of stressful life events.

The role of maternal care in borderline personality disorder and dependent life stress

BACKGROUND

Borderline Personality Disorder (BPD) affects 0.9%-3.2% of adolescents, and more than 20% of inpatient adolescents. Life stress has been linked to BPD across the lifespan, and previous research in adults has linked BPD to dependent stress (i.e., stress induced by the individual). However, prior research has not examined dependent stress alongside BPD in adolescents. Additionally, the potential protective effect of maternal care has not been considered in this relation. This study tested a moderation model expecting that (1) BPD would be positively associated with dependent life stress, (2) maternal care would be negatively associated with BPD, and (3) maternal care would moderate the relation between BPD and dependent life stress.

METHOD

The sample consisted of 184 adolescents recruited from an inpatient psychiatric facility serving a diverse population in the Southwestern United States. Dependent life stress, BPD, and maternal care were measured using the UCLA Life Stress Interview, DSM-IV Childhood Interview for BPD, and Kerns Security Scale, respectively.

RESULTS

Results supported the first two hypotheses; BPD diagnosis was significantly, positively associated with dependent life stress, and negatively associated with maternal availability and dependability. Contrary to the third hypothesis, no significant evidence that maternal care acts as a buffer in the relation between BPD and dependent life stress was found.

CONCLUSIONS

Although maternal care was not found to moderate the association between BPD and dependent life stress, results supported previously found relations between BPD, dependent life stress, and maternal care, and did so within a diverse inpatient adolescent sample.

Interpersonal predictors of stress generation: Is there a super factor?

Hammen's (1991, Journal of Abnormal Psychology, 100, 555-561) seminal paper on stress generation highlighted the reciprocal relationship between stress and depression. Not only does stress predict depression, but women with a diagnosis of depression also experienced subsequent increased levels of stress. In the ensuing years, depression researchers have moved beyond clinical predictors and examined whether depression vulnerability factors also contribute to stress generation. This interest has led to a growing focus on interpersonal vulnerability factors that contribute to stress generation. To date, the research examining interpersonal predictors of stress generation has tended to examine vulnerability factors singly and thus potential overlap and unique predictions among vulnerability factors have not been determined. This study examines interpersonal vulnerability factors from various schools of thought (dependency, attachment, and unmitigated communion) as predictors of interpersonal stress generation. Three hundred and sixty-four young adults completed baseline measures of interpersonal vulnerabilities and provided weekly reports of depressive symptoms and stressful life events. Multilevel models were estimated to examine their unique predictions of interpersonal stress generation. Despite converging theories, there does not appear to be a single super factor. Of the interpersonal vulnerability factors tested, anxious attachment emerged as a consistent predictor of interpersonal stress generation both when examined singly and when in combination with related variables.

Vulnerability-specific stress generation: an examination of depressogenic cognitive vulnerability across multiple domains

BACKGROUND AND OBJECTIVES

Although there is supporting evidence for the stress generation hypothesis (i.e., the tendency for depression-prone individuals to experience more negative dependent events influenced by their behaviors and characteristics), additional research is required to advance current understanding of the specific types of dependent events relevant to this effect. The present study elaborated on the stress generation hypothesis, in which the content of negative dependent events experienced by individuals is contingent upon, and matches, the nature of their particular vulnerabilities. This extension was tested within the context of Cole's competency-based model of depression.

DESIGN

Participants (n=185) were assessed at two time-points separated by a four-month interval.

METHODS

Self-perceived competence in academic, social, and appearance domains at the initial time-point were examined in relation to negative life events prospectively occurring over the four-month follow-up period, assessed using the "contextual threat" method.

RESULTS

Partial support was obtained for vulnerability-specific stress generation. Stress-generation specificity was found for self-perceived competence in appearance and academic domains, but not for self-perceived social competence.

CONCLUSIONS

The current findings are consistent with the possibility of a more complex relation between self-perceived social competence and domain-congruent stress generation. Individuals may be more likely to experience negative dependent events in domains matching their specific vulnerabilities.

Insecure attachment style as a vulnerability factor for depression: recent findings in a community-based study of Malay single and married mothers

The role of marital breakdown in women's mental health is of key concern in Malaysia and internationally. A cross-sectional questionnaire study of married and separated/divorced and widowed women examined insecure attachment style as an associated risk factor for depression among 1002 mothers in an urban community in Malaysia. A previous report replicated a UK-based vulnerability-provoking agent model of depression involving negative evaluation of self (NES) and negative elements in close relationships (NECRs) interacting with severe life events to model depression. This article reports on the additional contribution of insecure attachment style to the model using the Vulnerable Attachment Style Questionnaire (VASQ). The results showed that VASQ scores were highly correlated with NES, NECR and depression. A multiple regression analysis of depression with backward elimination found that VASQ scores had a significant additional effect. Group comparisons showed different risk patterns for single and married mothers. NES was the strongest risk factor for both groups, with the 'anxious style' subset of the VASQ being the best additional predictor for married mothers and the total VASQ score (general attachment insecurity) for single mothers. The findings indicate that attachment insecurity adds to a psychosocial vulnerability model of depression among mothers cross-culturally and is important in understanding and identifying risk.

Relational security moderates the effect of serotonin transporter gene polymorphism (5-HTTLPR) on stress generation and depression among adolescents

Previous research demonstrates that carriers of the short allele of the serotonin transporter gene (5-HTTLPR) show both greater susceptibility to depression in response to stressful life events and higher rates of generation of stressful events in response to depression. The current study examines relational security (i.e., self-reported beliefs about attachment security) as a moderator of these effects, building on emerging research suggesting that the short allele acts as a marker of sensitivity to the social environment. Participants were 354 Caucasian adolescents oversampled for maternal depression (137 male, 217 female), assessed at ages 15 and 20. Results indicated that the short allele predicted increased stress generation at age 20 among those with low age 15 security but decreased stress generation among those with high security, and revealed a three-way interaction between age 15 depression, age 15 security, and genotype, where depression predicted stress generation only among short allele carriers with low security. Further, among boys only, security interacted with genotype to predict longitudinal changes in depression diagnosis, with the s-allele predicting relative increases in probability of depression among boys with low security but decreases among boys with high security. Results support the notion of the short allele as a marker of social reactivity, and suggest that attachment security may buffer against the genetic vulnerability introduced by the short allele, in line with predictions of the differential susceptibility theory.

Negative attachment cognitions and emotional distress in mainland Chinese adolescents: a prospective multiwave test of vulnerability-stress and stress generation models

The present study examined the relation between attachment cognitions, stressors, and emotional distress in a sample of Chinese adolescents. Specifically, it was examined whether negative attachment cognitions predicted depression and anxiety symptoms, and if a vulnerability-stress or stress generation model best explained the relation between negative attachment cognitions and internalizing symptoms. Participants included 558 adolescents (310 females and 248 males) from an urban school in Changsha and 592 adolescents (287 female, 305 male) from a rural school in Liuyang, both in Hunan province located in mainland China. Participants completed self-report measures of negative attachment cognitions at baseline, and self-report measures of negative events, depression symptoms, and anxiety symptoms at baseline and at regular 1-month intervals for an overall 6-month follow-up (i.e., six follow-up assessments). Higher levels of negative attachment cognitions predicted prospective depression and anxiety symptoms. Furthermore, support was found for a stress generation model that partially mediated this longitudinal association. No support was found for a vulnerability-stress model. Overall, these findings highlight new developmental pathways for development of depression and anxiety symptoms in mainland Chinese adolescents.

Generation of life events in bipolar spectrum disorders: a re-examination and extension of the stress generation theory

The extent to which stress generation occurs in bipolar spectrum disorders (BSD) is not well understood. The present study examined whether 75 BSD participants experienced elevated rates of behavior-dependent life events, as compared with 38 normal control participants. Within the BSD group, we also examined whether depressive or hypomanic symptoms prospectively predicted increases in various types of negative and positive life events. Results indicated that BSD participants experienced overall increases in behavior-dependent events over the follow-up, as compared with normal controls. At the symptom level, the event generation process occurred in more specific event domains. Results suggest that the stress generation theory of unipolar depression can be extended to BSD and that the type of generated events may be polarity-specific.

A longitudinal investigation of the impact of life stress on HIV treatment adherence

Suboptimal antiretroviral adherence is associated with poorer HIV outcomes. Psychosocial factors, including life stress, depression and coping, may influence adherence behavior. This prospective investigation sought to examine the impact of life stress (acute life events, chronic stress, and perceived stress), depression, and coping style on adherence to HIV treatment regimes over time. Participants were 87 treatment-seeking HIV-infected individuals recruited from an urban HIV clinic. They completed clinician-administered interviews and self-report questionnaires at baseline and 3-month follow-up. Acute life events and chronic stress prospectively predicted decreases in treatment adherence more strongly among individuals in a major depressive episode (n = 21) compared to non-depressed individuals (n = 66). Coping style did not appear to be the mechanism by which life stress influenced adherence among depressed HIV-infected individuals. These findings demonstrate that life stress has toxic effects for depressed individuals and suggest that treatment adherence interventions with depressed individuals could be enhanced via development of stress management skills.

Stress generation in depression: A systematic review of the empirical literature and recommendations for future study

Within the past 20 years, depression research has given increasing consideration to the possibility of complex and reciprocal relations between stress and depression. Not only does stress increase risk for depression (i.e., a stress exposure model of depression), but depression, or depressogenic vulnerabilities, in turn, also increases susceptibility to stressful events that are at least in part influenced by the individual (i.e., stress generation; Hammen, 1991). The present review provides a systematic examination of the stress generation literature to date, with specific focus given to depression and depressogenic risk factors (i.e., past stress, negative cognitive styles, and personality and interpersonal vulnerabilities) as predictors of the stress generation effect, as well as gender differences in stress generation, the sequelae of generated stress, and the relative specificity of this phenomenon to depression. The research thus far appears most consistent in supporting the role of depression in predicting generated stress, although more research is still required. In addition to highlighting these findings, methodological limitations and conceptual gaps in the literature are discussed with the view of informing future research in this area.

An Examination of Integrated Cognitive-Interpersonal Vulnerability to Depression: The Role of Rumination, Perceived Social Support, and Interpersonal Stress Generation

This research examined an integration of cognitive and interpersonal theories of depression by investigating the prospective contribution of depressive rumination to perceptions of social support, the generation of interpersonal stress, and depressive symptoms. It was hypothesized that depressive ruminators would generate stress in their relationships, and that social support discontent would account for this association. Further, depressive rumination and dependent interpersonal stress were examined as joint and unique predictors of depressive symptoms over time. Participants included 122 undergraduate students (M age = 19.78 years, SD = 3.54) who completed assessments of depressive rumination, perceptions of social support, life stress, and depressive symptoms across three waves, each spaced 9 months apart. Results revealed that social support discontent accounted for the prospective association between depressive rumination and dependent interpersonal stress, and that both depressive rumination and dependent interpersonal stress contributed to elevations in depressive symptoms over time. These findings highlight the complex interplay between cognitive and interpersonal processes that confer vulnerability to depression, and have implications for the development of integrated depression-focused intervention endeavors.

Differential predictors of critical comments and emotional over-involvement in first-episode psychosis

BACKGROUND

Little research has focused on delineating the specific predictors of emotional over-involvement (EOI) and critical comments (CC) in the early course of psychosis. The purpose of this study was to investigate the differential relationships of EOI and CC with relevant predictors in relatives of first-episode psychosis (FEP) patients.

METHOD

Baseline patient-related factors including psychotic symptoms, depression and duration of untreated psychosis (DUP) and carer attributes comprising CC, EOI, burden of care and carers' stress and depression were assessed in a cohort of 63 remitted FEP patients and their relatives. Carers were reassessed at 7 months follow-up.

RESULTS

Baseline analysis showed that EOI was more strongly correlated with family stress compared with CC, whereas CC yielded a stronger association with DUP than EOI. Carers' CC at follow-up was not significantly predicted by either baseline family stress, burden of care or patient-related variables. Conversely, baseline EOI predicted both family stress and burden of care at 7 months follow-up. Finally, family burden of care at follow-up was a function of baseline EOI and patients' depressive symptoms.

CONCLUSIONS

This study provides preliminary support to the postulate that EOI and CC may be influenced by separate factors early in the course of psychosis and warrant future research and therapeutic interventions as separate constructs. Implications for family interventions in the early phase of psychosis and the prevention of CC and EOI are discussed.

Corumination, interpersonal stress generation, and internalizing symptoms: accumulating effects and transactional influences in a multiwave study of adolescents

This multiwave longitudinal study investigated potential transactional and accumulating influences among corumination, interpersonal stressors, and internalizing symptoms among a sample of early and middle adolescents (N = 350; 6th-10th graders). Youth completed self-report measures of corumination at Times 1, 2, and 4, and negative life events, internalizing symptoms (general depressive, specific anhedonic depressive, anxious arousal, general internalizing), and externalizing problems at all four time points (5 weeks between each assessment across 4 months). Results supported hypotheses. First, baseline corumination predicted prospective trajectories of all forms of internalizing symptoms but not externalizing problems. Second, baseline corumination predicted generation of interpersonal-dependent, but not interpersonal-independent or noninterpersonal stressors. Third, interpersonal-dependent events partially mediated the longitudinal association between baseline corumination and prospective internalizing symptoms. Fourth, a transactional, bidirectional set of associations was supported in that initial internalizing symptoms and stressors predicted later elevations in corumination, and in turn, corumination predicted later symptoms through the mediating role of interpersonal stressors to complete both streams in the transactional chain of influence. Fifth, girls and older adolescents exhibited higher corumination, but neither age nor sex moderated any associations. These findings are discussed within a transactional, developmental cascade model.

Oxytocin receptor polymorphisms and adult attachment style in patients with depression

Much evidence of an association between specific attachment styles and depression prompted us to investigate, in depressive disorders, the potential role of polymorphisms within the gene encoding the receptor of the main neurohormone involved in attachment processes, oxytocin. For this purpose, two single nucleotide polymorphisms (SNPs), 6930G>A (rs53576) and 9073G>A (rs2254298), within the oxytocin receptor gene (OXTR), were studied in a cohort of 185 patients with major depression (50.3%) or bipolar I or II disorders (49.7%) and 192 matched healthy controls. A positive association between the GG genotype of OXTR SNPs (6930G>A or 9073G>A) and unipolar depression was demonstrated. In this group, GG individuals showed high scores on Attachment Style Questionnaire factors that have been previously associated with depression. Moreover, the GG genotype was also associated with high levels of adult separation anxiety. These findings support the involvement of the oxytocinergic system in the mechanisms that underlie depression and specific adult attachment styles.

Adult attachment in bipolar 1 disorder

OBJECTIVES

To determine how security of adult attachment style is related to the mania, major depression and euthymic mood states in bipolar 1 (BP1) disorder.

DESIGN

An observational cross-sectional study.

METHOD

One hundred and seven BP1 patients (34 in a manic type episode, 30 in major depressive episode, and 43 in remission) and 41 healthy controls similar in age, gender, reading age, and education were recruited. The groups were compared on self-reported mean and preferred attachment style controlling for psychiatric comorbidity.

RESULTS

Preferred attachment style was insecure in 84 (78%) BP1 patients but only 13 (32%) healthy controls (chi(2)=34.3, df=3, and p<.001). Healthy controls reported higher secure attachment, lower anxious, and lower preoccupied attachment scores than all groups of patients with bipolar disorder, although the scores for secure attachment in mania and preoccupied attachment in euthymic patients were not significantly different from healthy controls. Overall, within the bipolar groups, anxious attachment style varied little with mood but mania was associated with higher secure and preoccupied attachment style, and depression with higher preoccupied and lower dismissing attachment style scores.

CONCLUSIONS

Insecure attachment is found in most patients with BP1 disorder. Attachment style is affected by mood episodes so it should be assessed when a patient with bipolar disorder is in remission with minimal residual depressive or manic symptoms.

Adjustment Disorder: epidemiology, diagnosis and treatment

BACKGROUND

Adjustment Disorder is a condition strongly tied to acute and chronic stress. Despite clinical suggestion of a large prevalence in the general population and the high frequency of its diagnosis in the clinical settings, there has been relatively little research reported and, consequently, very few hints about its treatments.

METHODS

the authors gathered old and current information on the epidemiology, clinical features, comorbidity, treatment and outcome of adjustment disorder by a systematic review of essays published on PUBMED.

RESULTS

After a first glance at its historical definition and its definition in the DSM and ICD systems, the problem of distinguishing AD from other mood and anxiety disorders, the difficulty in the definition of stress and the implied concept of 'vulnerability' are considered. Comorbidity of AD with other conditions, and outcome of AD are then analyzed. This review also highlights recent data about trends in the use of antidepressant drugs, evidence on their efficacy and the use of psychotherapies.

CONCLUSION

AD is a very common diagnosis in clinical practice, but we still lack data about its rightful clinical entity. This may be caused by a difficulty in facing, with a purely descriptive methods, a "pathogenic label", based on a stressful event, for which a subjective impact has to be considered. We lack efficacy surveys concerning treatment. The use of psychotropic drugs such as antidepressants, in AD with anxious or depressed mood is not properly supported and should be avoided, while the usefulness of psychotherapies is more solidly supported by clinical evidence. To better determine the correct course of therapy, randomized-controlled trials, even for the combined use of drugs and psychotherapies, are needed vitally, especially for the resistant forms of AD.

Interpersonal predictors of stress generation

Hammen (1991) provided evidence for a stress generation process in which individuals with a history of depression contributed to the occurrence of stressors, especially interpersonal and conflict events. However, few studies have examined the factors contributing to stress generation. This study examines aspects of individuals' interpersonal style, operationalized as attachment, dependency, and reassurance seeking, as predictors of conflict stress generation within romantic relationships. These effects were examined both prospectively over a 4-week period and cross-sectionally using a 14-day daily diary in a sample of female college students. Overall, there was significant evidence that interpersonal style contributes to the occurrence of interpersonal stressors. Specifically, anxious attachment and reassurance seeking prospectively predicted romantic conflict stress over a 4-week period, and a variety of interpersonal behaviors were associated with romantic conflict stressors on a daily basis. These results are interpreted in relation to previous literature, and limitations and directions for future research are discussed.

Non-treatment-related sudden gains in depression: The role of self-evaluation

A number of studies have demonstrated that recovery from depression is often marked by precipitous improvements during the course of treatment. The present research examined sudden gains occurring outside of the context of treatment in a sample of college students with current major depressive disorder (n=60), and tested whether variables pertaining to cognitive style, hope, self-evaluation, and life events would be associated with these gains. Results indicated that 60% of the sample experienced sudden gains, with over half of those sudden gains reversing before the end of the 9-week observation period. Sudden gainers were significantly less depressed at the end of the observation period but were no more likely to have achieved remission compared to non-sudden gainers. Although changes in cognitive style did not precede sudden gains, individuals with sudden gains had significantly higher self-esteem at baseline compared to non-sudden gainers. Furthermore, decreases in the frequency of social comparison occurred in the week prior to sudden gains. These results suggest that sudden gains do occur outside of the context of treatment and that self-evaluation processes may play an important role in recovery from depression.

The contribution of attachment security and social support to depressive symptoms in patients with metastatic cancer

The present study examines the association between disease-related factors, perceived social support, attachment security (i.e. attachment anxiety and avoidance), and the occurrence of depressive symptoms in a sample of patients with metastatic gastrointestinal or lung cancer. Results from a sample of 326 cancer outpatients with advanced disease indicate that disease-related factors are significantly associated with the occurrence of depressive symptoms, and the latter are inversely related to the degree of attachment anxiety and avoidance, and perceived social support. Attachment security (on the dimension of anxious attachment) significantly buffered the effect of disease-related factors on depressive symptoms, and perceived social support mediated the relationship between attachment security and depressive symptoms. The buffering effect of attachment security on depressive symptoms and its partial mediation through social support suggest that the interaction of individual, social, and disease-related factors contribute to the emergence of depressive symptoms in patients with metastatic cancer.