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Pain 127 (2007) 2734

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The relationship of adult attachment dimensions to pain-related fear,


hypervigilance, and catastrophizing
a,* b
Lachlan A. McWilliams , Gordon J.G. Asmundson
a
Department of Psychology, Acadia University, Wolfville, NS, Canada B4P 2R6
b
Faculty of Kinesiology and Health Studies, University of Regina, Canada

Received 29 December 2005; received in revised form 7 July 2006; accepted 7 July 2006

Abstract

Despite the prominence of fear-avoidance models of chronic pain, there is a paucity of research regarding the origins of pain-
related fear. Based on the premise that insecure attachment could be a developmentally based origin of elevated fear of pain, asso-
ciations between adult attachment dimensions and constructs included in fear-avoidance models of chronic pain were investigated.
Consistent with Bartholomew and Horowitzs [Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a
four-category model. J Pers Soc Psychol 1991;61:22644.] model, attachment was conceptualized as being comprised of a model of
self dimension (i.e., degree of anxiety regarding rejection based on beliefs of personal unworthiness) and a model of others dimen-
sion (i.e., degree of interpersonal mistrust and discomfort with interpersonal closeness). A large university student sample free of
chronic pain (N = 278) completed a measure of adult romantic attachment (i.e., Experiences in Close Relationships Questionnaire;
[Brennan KA, Clark CL, Shaver PR. Self-report measurement of adult attachment: an integrative overview. In: Simpson JA, Rholes
WS, editors. Attachment theory and close relationships. New York: The Guilford Press, 1998. p. 4676.]), the Fear of Pain Ques-
tionnaire-III [McNeil DW, Rainwater AJ. Development of the fear of pain questionnaire III. J Behav Med 1998;21:389410.], the
Pain Vigilance and Awareness Questionnaire [McCracken LM. Attention to pain in persons with chronic pain: a behavioural
approach. Behav Ther 1997;28:27184.], and the Pain Catastrophizing Scale [Sullivan MJ, Bishop SR, Pivik J. The pain catastro-
phizing scale: development and validation. Psychol Assess 1995;7:24532.]. It was hypothesized that insecure attachment would be
positively associated with reports of pain-related fear, hypervigilance, and catastrophizing and that the model of self dimension
would be the attachment variable most strongly associated with these variables. Correlation and multiple regression analyses
supported these hypotheses. The model of self dimension had signicant positive associations with each of the fear-avoidance
constructs. The model of others dimension had a signicant positive association with pain catastrophizing, but was not signicantly
associated with fear of pain and pain hypervigilance. Future research directions and potential clinical implications are discussed.
2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Keywords: Fear-avoidance models; Fear of pain; Catastrophizing; Adult attachment

1. Introduction disability (Asmundson et al., 2004a). However, there has


been little research regarding the origins of pain-related
Many studies have supported the notion that pain-re- fear. Attachment theory (Bowlby, 1969) has been pro-
lated anxiety and fear lead to chronic pain and increased posed as a framework for understanding the develop-
ment of chronic pain. Given that attachment theory
suggests attachment insecurity is associated with exag-
* gerated negative appraisals, insecure attachment holds
Corresponding author. Tel.: +1 902 585 1495; fax: +1 902 585
1078. promise as a developmentally based origin of elevated
E-mail address: Lachlan.Mcwilliams@acadiau.ca (L.A. McWilliams). fear of pain.

0304-3959/$32.00 2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.pain.2006.07.020
28 L.A. McWilliams, G.J.G. Asmundson / Pain 127 (2007) 2734

Bartholomew and Horowitzs (1991) inuential mod- 2. Method


el posits that adult attachment styles are based on two
orthogonally related dimensions. Model of self refers 2.1. Participants and procedure
to the attachment dimension that can range from an
Participants were recruited from the University of Manito-
internalized sense of self-worth to anxiety regarding
bas Department of Psychology subject pool after the study
rejection based on beliefs of personal unworthiness.
had received approval from the Psychology/Sociology
Model of others refers to a dimension ranging from trust Research Ethics Board. Potential participants were informed
and comfort with intimacy to mistrust and avoidance of that the study was aimed at understanding relationship styles
close relationships. Each model can be dichotomized to and pain-related behaviors. Individuals interested in partici-
yield four unique attachment styles, including one that is pating were asked to attend one of several data collection ses-
secure (i.e., positive models of self and others) and three sions. Those willing to participate were asked to provide
that are insecure (i.e., preoccupied: negative self/positive informed written consent and then completed a questionnaire
others; fearful: negative self/negative others; dismissing: package. All participants received course credit for an intro-
positive self/negative others). ductory psychology course as compensation for their eorts.
Recent research regarding the potential role of inse- A total of 308 individuals participated in the study. In order
to ensure the sample was comprised only of those free of
cure attachment in chronic pain has focused on the pos-
chronic or persistent pain, a series of questions (see below)
sibility that those with insecure attachment make more
were used to identify those experiencing such pain. When this
negative appraisals of pain. For example, in a chronic procedure was applied, 30 participants (9 males and 21
pain sample, Meredith et al. (2005) found that attach- females) were classied as having chronic pain. The remaining
ment anxiety (similar to a negative model of self) was participants were free of chronic pain (N = 278), had an aver-
positively associated with a measure assessing appraisals age age of 20.22 (SD = 3.97) years, were primarily single
of pain as threatening. They also found comfort with (92.8%), and were almost equally distributed with regard to
closeness (similar to positive model of others) to be pos- gender (145 males and 136 females). A majority of participants
itively associated with more adaptive appraisals (i.e., reported being Caucasian (63.3%), but the sample also includ-
seeing pain as a challenge). Positive associations ed those identifying themselves as Asian (19.8%), Native (or
between attachment variables and pain catastrophizing Canadian Aboriginal) (4.7%), or Black (2.2%). A small num-
ber of participants endorsed the Other category (7.6%), and
have also been found (Ciechanowski et al., 2003;
a few did not provide a response regarding their racial or eth-
Meredith et al., 2006).
nic background (2.5%). The chronic pain group was slightly
Based on the premise that insecure attachment could older (M = 22.40, SD = 7.19) than the study sample, but this
be a developmentally based origin of elevated levels of dierence was only marginally signicant [t(30.94) = 1.78,
fear of pain, the present study was designed to evaluate p = .08 (2-tailed test)]. A chi-square analysis indicated that
relationships between adult attachment dimensions and there was a disproportionate number of females in the chronic
individual dierence variables included in contemporary pain group [v2(1) = 4.98, p = .02 (2-tailed test)]. The study
fear-avoidance models of chronic pain (see Vlaeyen and sample did not signicantly dier from the chronic pain group
Linton, 2000) fear of pain, hypervigilance, and catas- on the attachment or pain appraisal variables. The chronic
trophizing. A sample free of chronic pain was utilized pain group was not included in any of the subsequent analyses.
in order to determine whether relationships between
2.2. Measures
adult attachment and pain-related variables exist prior
to development of chronic pain. In general, it was
A brief demographics questionnaire was used to obtain
hypothesized that those with more negative models of information from the participants regarding their age, gender,
self and others would report greater levels of pain-relat- marital status, and ethnic/racial background. Several questions
ed fear, hypervigilance, and catastrophizing. Based on concerning ongoing pain and pain history were included in
Bartholomew et al.s (1997) suggestion that sensitivity order to determine whether the respondents should be consid-
to potential threat is characteristic of those with nega- ered as having chronic or persistent pain. They were asked to
tive models of self, it was hypothesized that the model indicate whether they currently had pain or discomfort that
of self dimension would have relatively strong associa- has persisted continuously or intermittently for longer than
tions with the fear-avoidance variables. Based on three months? This method was adapted from the method
research regarding attachment and another fear con- utilized in Elliott et al.s (1999) epidemiological study of chron-
ic pain. Those indicating the presence of such pain were asked
struct (viz., anxiety sensitivity; e.g., Watt et al., 2005),
a series of follow-up questions regarding the frequency of their
it was expected that the model of others dimension
pain, the intensity of their pain, and physician contact regard-
would have relatively weak associations with the fear- ing the pain. The pain intensity rating was based on the present
avoidance variables. Grin and Bartholomew (1994) pain intensity rating method used in the McGill Pain Question-
demonstrated that relationships between attachment naire (Melzack, 1975) and ranged from 0 (No pain) to 5
dimensions and dependent variables may be moderated (Excruciating). Individuals were considered to have chronic
by the other attachment dimension, so interaction eects or persistent pain if they (a) reported the presence of continu-
were also tested. ous or intermittent pain over the past 3 months, (b) indicated
L.A. McWilliams, G.J.G. Asmundson / Pain 127 (2007) 2734 29

that the pain occurred almost everyday or more, (c) rated the The Pain Catastrophizing Scale (PCS; Sullivan et al., 1995)
pain intensity as discomforting or worse, and (d) reported con- is a 13-item self-report measure designed to assess catastrophic
sulting with a physician regarding this pain. thoughts or feelings accompanying the experience of pain.
The Experiences in Close Relationships Questionnaire Respondents are asked to reect on past painful experiences
(ECR; Brennan et al., 1998) includes an 18-item Model of Self and to indicate the degree to which each of the 13 thoughts
scale and an 18-item Model of Others scale (also commonly or feelings are experienced when in pain. The questionnaire
referred to as Anxiety and Avoidance scales, respectively). uses a 5-point scale ranging from 0 (Not at all) to 4 (All the
Respondents are asked to indicate their level of agreement with time). The PCS has been found to be reliable (i.e., a = .95;
a series of statements concerning their romantic relationship Osman et al., 2000) and to have a testretest reliability of .70
experiences using a response format ranging from 1 (Disagree when readministered over periods ranging from 8 to 12 weeks
strongly) to 7 (Agree strongly). Scale scores are created by tak- (Sullivan et al., 1995). Supportive of its construct validity, PCS
ing the average score of the items from each scale. Higher scores have been found to be positively associated with cata-
scores indicate more negative models. The ECR was developed strophic thoughts in response to an experimental pain proce-
based on a series of analyses (i.e., factor analytic and correla- dure (i.e., the cold pressor) and to contribute signicant and
tional) designed to select items from existing attachment mea- unique variance to the prediction of pain intensity during such
sures that best capture the two attachment dimensions. procedures (Sullivan et al., 1995).
Brennan et al. (1998) reported a-coecients > .90 for each of
these scales and reported several analyses supportive of their
3. Results
construct validity. A recent item response theory analysis of
several commonly used measures of adult attachment indicat-
ed that the ECR scales showed the greatest degree of measure- All statistical analyses were conducted with the Sta-
ment precision (Fraley et al., 2000). Throughout this paper, the tistical Package for the Social Sciences (version 14.0
terms Model of Self and Model of Others (capitalized) are used for Windows). In order to determine whether the data
to refer to the ECR scales whereas the terms model of self and conformed to the assumptions of the statistical tests
model of others (not capitalized) are used to refer to the attach- used, the KolmogorovSmirnov test was used to deter-
ment constructs operationalized by the ECR. mine whether the data deviated from the normal distri-
The Fear of Pain Questionnaire-III (FPQ-III; McNeil and bution. Most variables did not signicantly deviate from
Rainwater, 1998) is a 30-item self-report measure of fear of the normal distribution (KolmogorovSmirnov Z values
pain. This measure presents a series of hypothetical painful sit-
in parentheses) including the Model of Self (0.63), the
uations (e.g., breaking ones arm) and requires the respondent
FPQ-III (0.91), the PVAQ (1.18), and the PCS (1.10).
to rate the degree of fear they anticipate experiencing related to
the painful event. A Likert scale ranging from 1 (Not at all) to 5 The distribution of Model of Others scores did signi-
(Extreme) is used. The FPQ-III is comprised of three subscales cantly dier from the normal distribution (1.39,
assessing Fear of Severe Pain (e.g., Being in an automobile p = .04) as did age (4.69, p < .001). Both of these
accident), Fear of Minor Pain (e.g., Biting your tongue while variables were positively skewed (skewness of Model
eating), and Fear of Medical Pain (e.g., Having a blood sam- of Others = 0.37, skewness of age = 3.38). The Model
ple drawn with a hypodermic needle). The total FPQ-III score of Others variable became normally distributed after a
is obtained by summing the responses to each item. McNeil and square root transformation was applied (Kolmogorov
Rainwater (1998) reported that the FPQ-III has excellent inter- Smirnov Z = 1.16, n.s.; skewness = 0.03). Age could
nal consistency (i.e., a = .92), adequate testretest reliability not be successfully transformed, so it was dichotomized
(i.e., .74) over a 3-week period, and good construct validity.
using a median split. Analyses using the transformed
The Pain Vigilance and Awareness Questionnaire (PVAQ;
Model of Others variable and the dichotomous age
McCracken, 1997) is a 16-item measure of attention to pain.
The original PVAQ was designed for use with chronic pain variable did not dier substantially from those
patients and requires respondents to consider their behavior performed on the non-transformed variables, so the
over the last 2 weeks and to indicate how frequently each item non-transformed results are presented.
is true using a scale ranging from 0 (Never) to 5 (Always). Descriptive statistics for each of the self-report mea-
McCracken (1997) reported ndings supportive of its internal sures are presented in Table 1 along with their internal
consistency, testretest reliability, and construct validity. More consistency coecients and their inter-correlations
recently, Roelofs et al. (2002) provided evidence supportive of (2-tailed statistical tests were used for all correlation
its convergent and divergent validity. They found PVAQ and regression analyses). From this table it can be seen
scores were highly correlated with measures of related con- that each measure had an acceptable level of internal
structs, such as catastrophizing, and weakly correlated with
consistency. The preliminary correlational analyses
measures of unrelated constructs, such as trait anxiety. A
revealed that: (a) the two attachment scales did not over-
slightly modied version of the PVAQ suitable for use with
non-clinical samples was used. McWilliams and Asmundson lap or share signicant variance with each other, (b) the
(2001) reported that this modied version of the PVAQ has pain-related measures all shared common variance, (c)
excellent internal consistency (a = .92) and that its correlations Model of Self was positively associated with each of
with pain-related variables (e.g., pain severity ratings and pain- the pain-related measures, and (d) Model of Others
related restriction in activities) were supportive of its construct had a signicant positive association with the PCS,
validity. but was not signicantly associated with other two
30 L.A. McWilliams, G.J.G. Asmundson / Pain 127 (2007) 2734

Table 1
Self-report measure descriptive statistics and correlations (N = 278)
Measure Cronbachs a Mean SD Correlations
1 2 3 4 5
1. Model of Self .90 3.27 1.11 .08 .18** .21*** .26***
2. Model of Others .91 2.87 1.07 .03 .03 .14*
3. FPQ-III .93 76.78 20.28 .30*** .34***
4. PVAQ .75 36.16 14.58 .38***
5. PCS .88 15.70 9.01
Note. Model of Self and Model of Others are from the Experiences in Close Relationships Questionnaire. FPQ-III, Fear of Pain Questionnaire III;
PVAQ, Pain Vigilance and Awareness Questionnaire; PCS, Pain Catastrophizing Scale.
*
p 6 .05.
**
p 6 .01.
***
p 6 .001 (2-tailed tests).

pain-related variables. In these correlation analyses, and (1, 272) = 0.39, n.s.] or PCS [F Change (1, 272) = 2.46,
in the regression analyses reported below, ndings using n.s.] scores. However, the addition of Step 2 did signi-
the FPQ-III subscales were similar to those obtained cantly improve the statistical model predicting PVAQ
with total FPQ-III scores, so only those regarding the scores [Change F(1, 272) = 6.67, p = .01]. The adjusted
later are reported. R2 value from this model indicated that the inclusion
There were no specic hypotheses regarding potential of the interaction term accounted for an additional
moderation eects. However, Grin and Bartholomew 1.9% of the variance in PVAQ scores. The standardized
(1994) noted that it is important to consider the combi- b values from Step 2 of these models are also reported in
nation of the two attachment dimensions and demon- Table 2. From this table it can be seen that the interac-
strated that the relationships between attachment tion variable had a signicant positive association with
dimensions and dependent variables may be moderated the PVAQ. To interpret this signicant interaction
by the other attachment dimension. Hierarchical multi- eect, a median split was used to divide the sample into
ple linear regressions were used to test whether the two a group comprised of those with a relatively negative
attachment dimensions interacted in the prediction of model of others (i.e., those with scores above the median
the dependent variables. These analyses involved two on the Model of Others scale) and a group comprised of
steps. In Step 1, the demographic variables (viz., age those with a relatively positive models of others (i.e.,
and gender) and the two ECR scales were entered. In those with scores below the median on the Model of
Step 2, the interaction term was entered. Following Others scale). Correlations between Model of Self and
Aiken and Wests (1991) recommendations for testing
interaction eects, the ECR scales were centered (i.e.,
put in deviation score form with means of zero) and Table 2
Standardized b values in the hierarchical linear regression models
the interaction term (a variable created by multiplying
the two ECR scales) was formed using the centered ver- Independent variables Dependent variables
sions of the ECR scales. FPQ-III PVAQ PCS
The regression models in Step 1 were statistically sig- Step 1
nicant when the FPQ-III [F(4, 273) = 12.18, p < .001], Age .08 .07 .09
PVAQ [F(4, 273) = 4.26, p = .002], and the PCS Gender .33*** .11 .18**
Model of Self .22*** .21*** .25***
[F(4, 273) = 8.49, p < .001] were included as dependent Model of Others .03 .02 .13*
variables. Respectively, the adjusted R2 values indicated
Step 2
that the nal models accounted for 13.9%, 4.5%, and
Age .08 .06 .10
9.8% of the variance in FPQ-III, PVAQ, and PCS Gender .33*** .11 .18**
scores. The standardized b values from these models Model of Self .21*** .22*** .26***
are reported in Table 2. They indicate that participants Model of Others .03 .03 .14*
with an insecure model of self reported higher levels of Interaction (model of Self
by model of Others) .04 .15** .09
pain-related fear, hypervigilance, and catastrophizing.
The Model of Others dimension of attachment had a Note. Model of Self and model of Others are from the Experiences in
signicant positive association with PCS scores, but Close Relationships Questionnaire. FPQ-III, Fear of Pain Question-
naire III; PVAQ, Pain Vigilance and Awareness Questionnaire; PCS,
was not signicantly associated with the other pain-re- Pain Catastrophizing Scale.
lated measures. *
p 6 .05.
The addition of Step 2 did not signicantly improve **
p 6 .01.
***
the statistical models predicting FPQ-III [F Change p 6 .001 (2-tailed tests).
L.A. McWilliams, G.J.G. Asmundson / Pain 127 (2007) 2734 31

PVAQ scores were examined in these two groups. The as expected, the PVAQ scores of the secure (M = 35.86,
correlation coecients indicated that there was a signif- SD = 13.38) and preoccupied (M = 37.10, SD = 11.77)
icant positive association between Model of Self and groups did not dier signicantly from each other or
PVAQ scores amongst those with negative models of from those of the other attachment categories. The
others [r(137) = .36, p < .001] and that there was no sta- examination of PVAQ scores across attachment catego-
tistically signicant association between Model of Self ries was used to further interpret the interaction eect
and PVAQ scores amongst those with positive models obtained with the PVAQ. Since signicant interaction
of others [r(137) = .04, n.s.]. eects were not found with regard to the FPQ-III and
Fraley and Waller (1998) reported a taxometric anal- the PCS, group comparisons were not made regarding
ysis that indicated model of self and model of others are these variables.
most appropriately conceptualized as continuous
dimensions [i.e., people vary in degrees along these 4. Discussion
dimensions rather than possessing qualitatively dierent
working models (e.g., insecure models of self versus Based on the premise that insecure attachment
positive models of self)]. Nonetheless, they also noted could be a developmentally based origin of elevated
that the use of attachment taxons, or categories, may fear of pain, the present study investigated associations
more accurately reect how attachment is typically con- between adult romantic attachment variables and a
ceptualized. In order to further explore the interaction range of specic constructs included in contemporary
eect obtained with the PVAQ in a manner consistent fear-avoidance models of chronic pain. It was hypoth-
with this more intuitively appealing approach, dierenc- esized that the ECR Model of Self scale would be pos-
es between the attachment categories were considered. itively associated with reports of pain-related fear,
Utilizing classication coecients derived from a linear hypervigilance, and catastrophizing. It was also expect-
discriminant functions analysis conducted on a large ed that the ECR Model of Others scale would be only
university sample (N = 1082), Brennan et al. (1998) weakly associated with these fear-avoidance variables.
developed a method to assign individuals to one of the Both of these hypotheses were supported as the ECR
attachment categories based on their scores on the two Model of Self scale had signicant positive correlations
attachment scales. This procedure classies individuals with the FPQ-III, PVAQ, and the PCS. In contrast,
into one of four possible categories in Bartholomews the ECR Model of Others scale had a signicant posi-
model. In the present sample, the majority of partici- tive relationship with the PCS, but had only small non-
pants (n = 107) were classied as having secure attach- signicant associations with the FPQ-III and the
ment. The other participants were approximately PVAQ.
equally distributed across the fearful (n = 58), preoccu- In the present study, those with negative models of
pied (n = 56), and dismissing (n = 57) attachment self reported greater levels of pain-related fear, hypervig-
categories. ilance, and catastrophizing than those with more posi-
If the ndings of the correlation and regression anal- tive models of self. Application of attachment theory
yses regarding the PVAQ were extrapolated to a cate- to the context of pain would suggest that those with neg-
gorical conceptualization of attachment, those with ative models of self view themselves as less capable of
fearful attachment (i.e., negative models of others and coping with pain and/or view themselves as unworthy
negative models of self) would be expected to be more of assistance from others during an episode of pain.
vigilant to pain than those with dismissing attachment The nding that model of others was signicantly asso-
(i.e., negative models of others and positive models of ciated with only catastrophizing was not anticipated.
self). It would also be expected that those with dismiss- However, Sullivan et al.s (2001) communal coping
ing, preoccupied (i.e., negative models of self and posi- model of pain-related catastrophizing may provide a
tive model of others) and secure (i.e., positive models framework for understanding this nding. This model
of self and others) attachment would not signicantly suggests that catastrophizing is a means of communicat-
dier with regard to PVAQ scores. An analysis of vari- ing distress and eliciting social support. Individual dif-
ance (ANOVA) indicated a trend eect for attachment ference variables related to this form of coping have
category [F(3, 274) = 2.437, p = .065]. As expected, post not yet been identied. The present ndings suggest that
hoc analyses (with Bonferroni corrections) indicated attachment variables may be related to the communal/
that the PVAQ scores of those with dismissing attach- catastrophizing form of coping described by Sullivan
ment (M = 32.39, SD = 14.24) were lower than those et al. Of particular relevance to contextualizing the pres-
with fearful attachment (M = 39.53, SD = 18.45), but ent ndings, it may be that those who perceive others as
this dierence was only marginally signicant generally unwilling to provide support may exaggerate
(p = .051). Given the loss of statistical power that results their distress in order to obtain the assistance of others.
from dichotomizing continuous variables, this failure to It is noteworthy that this type of relationship bears a
obtain a highly signicant nding is not surprising. Also striking resemblance to Kolbs (1982) observation that
32 L.A. McWilliams, G.J.G. Asmundson / Pain 127 (2007) 2734

patients complaints of pain are often attachment behav- more generally related to the tendency to respond neg-
iors designed to elicit caretaking behavior in others. atively to pain (e.g., catastrophizing in response to
Grin and Bartholomew (1994) indicated that rela- pain or appraising pain as a threat). The relationships
tionships between attachment dimensions and depen- between these negative responses to pain and attach-
dent variables may be moderated by the other ment variables found in clinical samples could be
attachment dimension. To explore this possibility mul- due to a third variable related to the experience of
tiple regression analyses were used to test for interac- chronic pain (e.g., a high level of disability leading
tion eects involving the two attachment dimensions. to both more negative response to pain and increased
Only in the case of pain hypervigilance was the inter- attachment insecurity). The present ndings do not
action term a statistically signicant predictor. To exclude this possibility, but they do demonstrate that
interpret this signicant interaction eect, two subsam- relationships between adult attachment and negative
ples dened by either a relatively negative model of responses to pain exist prior to development of chron-
others or a relatively positive model of others were ic pain. Given this situation, longitudinal research
created and the correlation between model of self regarding the causal role of attachment in the devel-
and hypervigilance was calculated within each group. opment of chronic pain is warranted.
The pattern of ndings revealed a moderation eect The present study utilized a measure of romantic
in which there was a statistically signicant positive attachment; however, the hypotheses were intended
relationship between model of self and hypervigilance to apply to attachment in general rather than the
that was only present amongst those with negative more specic domain of romantic attachment. Attach-
models of others. ment has been conceptualized and assessed in many
PVAQ scores have been shown to be signicantly dierent ways. In general, research (see Bartholomew
associated with FPQ-III and PCS scores (Roelofs and Shaver, 1998) has indicated that these methods
et al., 2003, 2002) and in the present study scores assess a core set of relational tendencies and that
on each of these measures were signicantly correlated attachment measures share more variance with each
with each other. Given this shared variance between other when they assess the same domain of attach-
the fear-avoidance variables, it is surprising that a sig- ment (e.g., peers, parents, romantic partners), are
nicant interaction eect was found with regard to the based on similar underlying models (e.g., 3 category,
PVAQ but not the other pain measures. The rst fol- 4 category, 1 global dimension, 2 dimensions), or uti-
low-up analyses used to interpret the interaction eect lize a common assessment strategy (e.g., interviews,
(correlations in negative and positive model of others self-report measures). Given such overlap, it is likely
subsamples) indicated that the combination of a nega- that the ndings of the present study would have been
tive model of others and positive model of self (i.e., similar had another related measure of attachment
dismissing attachment) was associated with the lowest been used (e.g., a measure including models of self
scores on the PVAQ. The second follow-up analyses and others related to peer relationships). Several
(between group comparisons) were consistent with recent studies support this notion. For example, Watt
this, but the ndings were not statistically signicant. et al. (2005) investigated the relationships between
It has been suggested (Bartholomew et al., 1997) that anxiety sensitivity and both romantic and close-rela-
those with dismissing attachment defensively exclude tionship attachment dimensions and obtained similar
distress from their awareness. The relatively low scores ndings across both types of attachment. More direct-
on the PVAQ of those with a dismissing attachment ly related to chronic pain, Meredith et al. (2005)
style may reect one way in which this tendency is obtained ndings similar to those of the present study
manifested. When considered across dependent vari- when utilizing a measure of adult attachment that did
ables the pattern of ndings is consistent with the not refer to a specic type of close relationship (i.e.,
notion that those with dismissing attachment tend to the Attachment Style Questionnaire; Feeney et al.,
suppress their awareness of pain, but once pain is 1994).
experienced they do not dier from other individuals In response to the growing empirical support for
with negative models of others (i.e., the fearful attach- postulates of fear-avoidance models of chronic pain,
ment group) in terms of their fearfulness and fear of pain has become the focus of specic treatment
catastrophizing. strategies (see Asmundson et al., 2004b). In brief,
While the cross-sectional nature of the study limits treatments aimed at reducing fear of pain have been
causal conclusions from being drawn, the ndings sug- based on strategies originally designed for treating
gest that insecure attachment could be a developmen- specic phobias, such as in vivo exposure. Findings
tally based origin of elevated fear of pain. In regarding this type of treatment are encouraging
conjunction with earlier ndings with chronic pain (e.g., Linton et al., 2002; Vlaeyen et al., 2002). The
patients (Ciechanowski et al., 2003; Meredith et al., current study has implications for expanding this
2005), they also suggest that insecure attachment is approach to treating pain-related fear. At the most
L.A. McWilliams, G.J.G. Asmundson / Pain 127 (2007) 2734 33

basic level, the present ndings suggest that those with Ciechanowski P, Sullivan M, Jensen M, Romano J, Summer H. The
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