ORIGINAL ARTICLE
Attachment Insecurity Moderates the Relationship
Between Disease Activity and Depressive
Symptoms in Ulcerative Colitis
Robert G. Maunder, MD,* William J. Lancee, PhD,* Jonathan J. Hunter, MD,*
Gordon R. Greenberg, MD,† and A. Hillary Steinhart, MD†
Background: Among people with ulcerative colitis, depression
occurs more frequently when inflammation is active. We hypothe-
sized that individual differences in interpersonal style affect the risk
that active disease will be accompanied by depressive symptoms.
Methods: In this study, disease activity, depressive symptoms, and
2 dimensions of interpersonal style, attachment anxiety and attach-
ment avoidance, were measured in 146 ulcerative colitis outpatients
at time 1 and in 99 of these patients at a second time-point, 7 to
37 months later. Test–retest correlations of attachment anxiety (r = 0.83,
P , 0.001) and attachment avoidance (r = 0.76, P , 0.001) con-
firmed that these dimensions are stable.
Results: There was a stepwise increase in the correlation between
time 2 disease activity and depression from the lowest tercile of at-
tachment anxiety (r = 0.00, P = 0.99), through the middle tercile
(r = 0.36, P = 0.05), to the highest tercile (r = 0.52, P = 0.002). For
attachment avoidance, disease activity and depression were only
significantly correlated in the highest tercile (r = 0.49, P = 0.005).
Conclusions: Attachment anxiety meets all tested criteria as a mod-
erator of the relationship between disease activity and depressive
symptoms. Further attention to interpersonal style as a moderator of
depressive risk in ulcerative colitis is warranted.
Key Words: attachment anxiety, depression, relationship style,
ulcerative colitis
(Inflamm Bowel Dis 2005;11:919–926)
T he prevalence of depression in individuals with ulcerative
colitis (UC) is similar or modestly higher than the prev-
alence of depression in healthy individuals,1–4 and depressive
symptoms are more common and more severe when disease is
Received for publication June 9, 2005; accepted July 14, 2005.
From the *Integrated Medicine Project, Department of Psychiatry, and
†Division of Gastroenterology, Mount Sinai Hospital and University of
Toronto, Toronto, Canada.
Supported by Canadian Institutes of Health Research Grant MOP-43985.
Reprints: R. Maunder, MD, Mount Sinai Hospital, 600 University Avenue,
Toronto, Canada M5G 1X5 (e-mail: rmaunder@mtsinai.on.ca)
Copyright Ó 2005 by Lippincott Williams & Wilkins
Inflamm Bowel Dis  Volume 11, Number 10, October 2005
active.5,6 Although in principle, the relationship between dis-
ease activity and depression could be bidirectional, there is
very little evidence that depressive symptoms precede UC in-
flammatory activity.7,8 Therefore, it is more likely that the rela-
tionship between disease activity and depression is caused by
the causal influence of active disease, whether UC acts through
the psychologic experience of being ill, through pathophysio-
logical changes associated with active inflammation, or through
some other mechanism.
The presence of depressive symptoms or the full syn-
drome of major depression during the course of UC is im-
portant for several reasons. The presence of depression in
medical illness is associated with amplification of symptom
severity, increased reporting of unexplained physical symp-
toms, increased use of health care resources, and compromised
treatment adherence.9 The negative effects of depression and
active disease on health-related quality of life and function are
additive.10 Thus, it is important to identify depression when it
occurs in the course of UC.
It would be valuable to identify moderators of the rela-
tionship between disease activity and depression in UC, par-
ticularly if identifying moderating factors allows for more
effective or earlier identification of depression through closer
scrutiny of high-risk populations. Identification of moderators
may also help to identify targets for therapeutic intervention.
Interpersonal variables, especially those related to social
support, attachment relationships, isolation, and bereavement,
have long been considered to add to the risk of developing
depression,11 and, thus, individual differences in patterns of
interpersonal interaction may help to explain why some people
become depressed when they are ill and others do not. At-
tachment theory is a particularly well-developed interpersonal
theory that describes the ways that people use close inter-
personal relationships to achieve a sense of security.12 Feeling
secure refers to a subjective sense of safety and comfort. Sev-
eral lines of evidence suggest that attachment theory may be
valuable in determining why there are individual differences in
the relationship between disease activity and depression and in
identifying the people who are at greatest risk.
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Maunder et al
In adult attachment theory, individuals are considered to
have relatively stable preferences and patterns of dealing with
others in close relationships. A person’s typical pattern of
relating to others in close relationships is called an attachment
style. Although attachment style is a construct that is unfa-
miliar to many internists, it is a sensible candidate moderator
of the relationship between disease activity and depression for
3 reasons. First, relationships between attachment style and
medical outcomes have been confirmed in several settings, in-
cluding associations with health care use,13 medically un-
explained symptoms,14 and depression.15,16 There is growing
attention to the impact of attachment relationships on the ex-
perience of life stress,17–19 on the ability of attachment relation-
ships to buffer stress,20 and on the influence of attachment
style on relationship between life stress and a variety of medi-
cal outcomes in people with serious illness.21 Second, our expe-
rience is that attachment style can be easily recognized by
clinicians without structured assessment tools or special psy-
chologic training once clinicians are familiar with basic aspects
of the construct. Third, modifications in physicians’ manage-
ment of patients based on recognition of patterns of inter-
personal style may reduce patient–provider difficulties.22–24
Attachment theory describes the ways that a child and
his or her primary caregiver interact during early development,12
resulting in reliably identifiable patterns of attachment style
during the second year of development.25 For example, each
person develops preferred strategies for approach and with-
drawal to other people who can provide security at the time of
stress. Patterns of approach and withdrawal are determined in
part by a person’s experience of the reliability, responsiveness,
and availability of others at times of need. Longitudinal studies
investigating the developmental continuity of patterns of at-
tachment support the general stability of attachment style over
time 26,27 and identify conditions under which it can be
modified.26,28–30 Adult attachments are not primarily with
parents. Whereas romantic partnerships are prototypic attach-
ment relationships in adulthood, any relationship that affects
one’s sense of security may be considered an attachment
relationship,31 and adults may have several people in their
‘‘inner circle’’ who serve this function.32
Self-report measures of adult attachment characterize an
individual’s attachment style along 2 dimensions.33,34 The first
is a dimension of dependency and concern about the avail-
ability and responsiveness of others, called attachment anxiety.
This dimension describes the degree to which an individual
prefers close contact with another adult (a partner, a confidante,
or a health care worker), is vigilant for the presence and re-
sponsiveness of the other, and depends on that contact for
reassurance and security. The second is a dimension of auton-
omy, called attachment avoidance. This dimension describes
the degree to which the individual requires independence
and interpersonal distance to negotiate situations that threaten
personal security. Attachment style is often categorized as
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Inflamm Bowel Dis  Volume 11, Number 10, October 2005
secure or insecure, where insecure attachment designates a
style high in attachment anxiety, high in attachment avoidance,
or both.
The purpose of this study was to test the hypothesis that
insecure attachment moderates the risk that active inflamma-
tion in UC will be associated with depression. That is, we
hypothesize that disease activity is more likely to be associated
with depression in people with high attachment anxiety or high
attachment avoidance. If this hypothesis is confirmed then it
may be possible to identify patients who are at high risk more
effectively, and even to identify them before the onset of
depression. It may also provide clues about how to intervene to
reduce the risk of depression.
MATERIALS AND METHODS
Three hundred sixty-one patients with UC confirmed by
endoscopy or biopsy, of at least 18 years of age, were identified
by chart review and contacted by telephone. Exclusion criteria
were colectomy and indications of cardiovascular illness
(exclusion criteria for an aspect of the study not reported here).
Forty percent (146) consented to participate and were assessed
by a gastroenterologist, including physical examination and
endoscopy, and completed self-reports of UC symptoms,
attachment style, and depressive symptoms at time 1 (T1).
Subjects were recontacted to provide information at a second
time-point through a mailed survey. Ninety-nine subjects (68%)
completed the measures of attachment style and depression
and the self-report items of the St. Mark’s index of UC
severity35 at time 2 (T2), which was 7 to 37 months after T1
(median = 686 d).
The St. Mark’s index35 grades general health (scored
0–3), abdominal pain (0–2), bowel frequency (0–2), stool
consistency (0–2), blood in stool (0–2), anorexia (0–1), nausea
and vomiting (0–1), abdominal tenderness (0–3), extraintes-
tinal manifestations (eye inflammation, arthralgia, oral ulcera-
tion, related skin lesions; 0–2), fever (0–2), and sigmoido-
scopic appearance (0–2), generating a summary index of
severity with scores ranging from 0 to 22. At T2, disease
activity was based on the summed score of self-report items of
the St. Mark’s index: general health, abdominal pain, bowel
frequency, stool consistency, blood in stool, anorexia, nausea,
and vomiting. A high correlation between full St. Mark’s index
and an index composed only of the self-report items (R = 0.98,
P , 0.001) has previously been reported in this same subject
sample.36 We, therefore, expected the self-report index to
provide a valid measure of disease activity in this group.
Attachment insecurity was measured with the Experi-
ence in Close Relationships-Revised (ECR-R) questionnaire,
a 36-item questionnaire that probes attitudes toward close
relationships with intimate partners. Each item is a statement
scored on a 7-point scale ranging from strongly disagree
to strongly agree. The attachment anxiety scale and the
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Inflamm Bowel Dis  Volume 11, Number 10, October 2005
attachment avoidance scale (18 items each) of the ECR-R have
been derived through the application of item-response theory
to choose the 36 best items from a pool of 323 attachment
items drawn from the commonly used attachment instruments,
all completed by 1086 undergraduate students.34,37 Although
there is no gold standard measurement of adult attachment, test
information (a measure of the extent to which the scale is
informative across the full range of the underlying trait) is
greater in the ECR-R than in any other commonly used at-
tachment self-report instrument.37
Depressive symptoms were measured with the Center
for Epidemiologic Studies–Depression Scale (CES-D), a
20-item self-report screening instrument.38 In large commu-
nity samples, a cut-off of 16 has identified 84% to 94% of
subjects classified as depressed by the Schedule of Affective
Disorder and Schizophrenia (SADS) structured interview, and
a score of less than 16 has correctly identified 60% to 64% of
subjects not classified as depressed on the SADS.39
Analyses were conducted in the following sequence to
test attachment anxiety and attachment avoidance as moder-
ators of the relationship between UC disease activity and
depression symptoms. For A to be a moderator of a relationship
between B and O, the following criteria must be met according
to the MacArthur model of mediators and moderators40: (1) B
precedes O, (2) A precedes B, (3) A is not associated with B,
and (4) different values of A result in different potency of
the relationship between B and O. Each of these criteria was
examined separately in our UC sample.
1. Disease activity precedes depression. The correlation be-
tween disease activity and depression is tested. The tem-
poral precedence of disease activity is not tested but is
assumed, based on previous longitudinal studies.7,8
2. Attachment insecurity precedes UC disease activity. In
theory, attachment style refers to a stable trait-like char-
acteristic with developmental roots that, therefore, precedes
current UC activity. Nonetheless, it is an empirical question
whether the self-report methods of measuring attachment
anxiety and attachment avoidance employed in this study
yield a measure that is or is not sensitive to change in the
context of changing disease activity. First, simple correla-
tions of attachment anxiety score at T1and at T2, several
months later, were calculated. Second, for each subject, T1
and T2 disease activity scores were coded as 1 maximum
score and 1 minimum score. The 95% confidence intervals
(CIs) of mean attachment anxiety at the time of maximum
disease activity and mean attachment anxiety at the time of
minimum disease activity were compared. These 2 tests
serve to show if anxiety attachment is stable and if it varies
with disease activity. Finally, as a methodological control
for precedence in time, attachment anxiety at T1 was tested
as a moderator of the effect size of the relationship between
disease activity and depression at T2, several months later.
This analysis was repeated for attachment avoidance.
q 2005 Lippincott Williams & Wilkins
Disease Activity and Depressive Symptoms in UC
3. Attachment insecurity is not correlated with disease activ-
ity. Pearson correlations of each dimension of attachment
insecurity and disease activity were calculated.
4. The strength of the relationship between disease activity
and depression is different at different levels of attachment
anxiety. Subjects were divided into 3 groups based on a
tercile split of attachment anxiety at T1. In each group, the
relationship between disease activity and depression at T2
was expressed as a Pearson correlation coefficient and as an
estimated effect size (h2). Effect sizes were estimated using
analysis of variance with CESD score as the dependent
variable and disease severity score as the sole independent
variable in each tercile of attachment anxiety. The analysis
was repeated for attachment avoidance.
To test for an interaction of attachment anxiety and
attachment avoidance, this analysis was repeated, splitting the
sample into 4 groups based on a median split of attachment
anxiety (high/low) and a median split of attachment avoidance
(high/low). Sample size does not permit examination of the
9-cell table that would result from using a tercile split of each
dimension of attachment insecurity in this analysis.
It is possible that this analysis could be biased by a
common underlying factor that influences self-reporting and
therefore is correlated with each of self-reported attachment
style, depressive symptoms, and UC symptoms. As a check
on this potential source of error, depressive scores were com-
pared in groups defined by physician-assessed items of the
St. Mark’s index only. Subjects were divided into those with
or without objective indications of inflammation on endoscopy
or physical examination. Depressive scores were compared be-
tween the active UC and inactive UC groups using a t test. This
comparison was repeated for subjects with high attachment
anxiety and subjects with low attachment anxiety.
This study was approved by the Research Ethics Boards
of Mount Sinai Hospital and the University Health Network.
All subjects provided informed consent.
RESULTS
Characteristics of the participants with respect to psy-
chologic and UC status are found in Table 1. Of 146 subjects,
81 (55.1%) had inactive disease (St. Mark’s score of 0 or 1) at
T1. Most of those with active disease were experiencing mild
to moderate symptoms; of the maximum possible St. Mark’s
score of 22, subjects’ scores ranged from 0 to 16; 90% of
scores were less than or equal to 5. In comparing participants
and nonparticipants at T2, nonparticipants were younger (mean,
38 versus 45 yr; P = 0.001), earlier in the course of their dis-
ease (mean, 11 versus 16 yr; P = 0.001), and experiencing
more depressive symptoms (mean CESD score, 13.6 versus
9.3; P = 0.009).
Table 2 shows a moderate concurrent association of
disease activity and depressive symptoms (r = 0. 30–0.28),
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Maunder et al Inflamm Bowel Dis  Volume 11, Number 10, October 2005

TABLE 1. Comparison of T1 Characteristics of Patients with UC Who Participated at T2 and Those Who Did Not
Statistical Significance of Difference
Full Group Nonparticipant at Participant at Between Nonparticipant and
(n = 146) T2 (n = 47) T2 (n = 99) Participant Groups (P)*

Female: number (%) 65 (44.5%) 20 (42.5%) 45 (45.4%) 0.86

Age: mean (SD) 42.7 (12.6) 37.6 (12.3) 45.2 (12.0) 0.001
Duration of UC (years): mean (SD) 14.6 (10.3) 10.8 (9.1) 16.4 (10.4) 0.001
UC disease activity: mean (SD) 2.2 (2.7) 2.5 (2.7) 2.1 (2.7) 0.37
Attachment anxiety: mean (SD) 2.5 (1.4) 2.7 (1.3) 2.3 (1.4) 0.08
Attachment avoidance: mean (SD) 2.7 (1.2) 3.0 (1.2) 2.6 (1.2) 0.06
Depressive symptoms: mean (SD) 10.7 (8.9) 13.6 (9.2) 9.3 (8.6) 0.009
*Significance of t test for difference of means, except sex, which was significance of x2.

a moderate concurrent association of attachment avoidance
and depression (r = 0.37–0.43), and a strong concurrent corre-
lation of attachment anxiety and depression (r = 0.56–0.70) at
each time-point. The correlation between disease activity and
depressive symptoms measured at different time-points was
weak and nonsignificant (r = 0.19). Disease severity had a
negligible and nonsignificant association to each dimension of
attachment insecurity at both time-points (r = 0.01–0.16).
With respect to the stability of attachment scores be-
tween time-points, the test–retest correlation of attachment
anxiety was 0.83 (P , 0.001) and of attachment avoidance was
0.76 (P , 0.001). At the time-point in which disease activity
was maximal for each individual, the mean attachment anxiety
score was 2.43 (95% CI, 2.16–2.70) and the mean attachment
avoidance score was 2.57 (95% CI, 2.27–2.87). At the time-
point at which disease activity was minimal, attachment inse-
curity scores were indistinguishable from the former (mean
attachment anxiety score, 2.39; 95% CI, 2.13–2.66; mean
attachment avoidance score, 2.74; 95% CI, 2.41–3.07).
Table 3 shows that, whereas depression scores differed
significantly between the highest and lowest terciles of attach-
ment anxiety and that the same was true for attachment avoid-
ance, there was no relationship between UC disease activity
and either dimension of attachment insecurity. It is also note-
worthy that significant depressive symptoms were present even
in the lowest tercile of attachment anxiety, as indicated by
4 subjects (12.1%) with a clinically significant depression
score (CESD $ 16).
Figure 1A shows a stepwise increase in the strength of
association between UC disease activity and depression as at-
tachment anxiety increases. In the lowest tercile of attachment
anxiety, the correlation between disease activity and depres-
sion did not differ from 0 (r = 0.002, P = 0.99), and the es-
timated effect size was 0. In the highest tercile of attachment
anxiety, the correlation was strong (r = 0.52, P = 0.002), and
the estimated effect size was 0.27.
Figure 1B shows a strong association between UC dis-
ease activity and depression in the highest tercile of attachment

TABLE 2. Intercorrelations Between Study Variables at T1 and T2 in 99 People with UC

T1 T2

Attachment Attachment Attachment

Avoidance Depression UC Activity Anxiety Avoidance Depression UC Activity

T1
Attachment anxiety 0.53† 0.56† 0.09‡ 0.83† 0.52† 0.61† 0.02‡
Attachment avoidance – 0.37† 0.11‡ 0.50† 0.76† 0.42† 0.06‡
Depression – – 0.30* 0.57† 0.32* 0.71† 0.19‡
Disease activity – – – 0.08‡ 0.16‡ 0.19 ‡ 0.40†
T2
Attachment anxiety – – – – 0.57† 0.70† 0.01‡
Attachment avoidance – – – – – 0.43† 0.01‡
Depression – – – – – – 0.28*
*P # 0.01; †P # 0.001; ‡P . 0.05.

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Inflamm Bowel Dis  Volume 11, Number 10, October 2005 Disease Activity and Depressive Symptoms in UC

TABLE 3. T1 Depression and Disease Activity Scores by Tercile Split of Attachment Scores
Depression (CESD Score) Disease Activity (St. Mark’s Index)

Mean (95% CI) CESD $16: Number (%) Mean (95% CI)

Attachment anxiety
Lowest tercile (n = 33)
Middle tercile (n = 33)
Highest tercile (n = 32)
Attachment avoidance
Lowest tercile (n = 35)
Middle tercile (n = 31)
Highest tercile (n = 32)
5.52 (3.08–7.95) 4 (12.1%) 1.97 (0.91–3.03)
7.72 (5.62–9.83) 6 (18.2%) 1.88 (1.23–2.52)
15.13 (11.64–18.61) 14 (43.8%) 2.41 (1.27–3.55)
3.43 (2.09–4.77) 1 (2.9%) 1.80 (0.82–2.77)
11.77 (8.89–14.64) 12 (38.7%) 1.55 (0.76–2.33)
13.63 (10.19–17.06) 11 (34.4%) 2.91 (1.86–3.96)

avoidance (r = 0.49, P = 0.005, estimated effect size = 0.24) Finally, the data were reanalyzed using physician-
and no correlation between disease activity and depression in determined inflammation from the endoscopic examination
the low and middle tertiles of attachment avoidance. instead of the St. Mark’s index to remove potential bias re-
Regarding possible interactive effects of attachment anx- sulting from self-reported symptoms of UC. This required ana-
iety and attachment avoidance, Figure 2 shows that, in a me- lyzing data from T1 only, because endoscopy was performed at
dian split (the highest degree of resolution available in this T1. As shown in Figure 3, the overall pattern of interaction
dataset), the correlation between disease activity and depres- between attachment and disease activity appears similar for
sion was negligible in all subjects with low attachment anxiety. attachment anxiety and attachment avoidance. However,
A correlation of 0.30 in the high anxiety–low avoidance group
was not statistically significant (n = 11), whereas a correlation
of 0.45 in the larger high anxiety–high avoidance group (n =
32) was significant (P = 0.009). It is noteworthy that subjects
in the high attachment anxiety group tended to also have high
avoidance (x2 = 18.27, P , 0.001).
Three further analyses were performed to test for pos-
sible sources of error. First, the table of correlations (Table 2)
was used to test for multicollinearity between the 3 variables
of the moderation model (T1 attachment anxiety or T1 at-
tachment avoidance, T2 depression, T2 disease activity). The
highest correlation between these variables was a correlation
of r = 0.61 between T1 attachment anxiety and T2 depression.
Thus, attachment anxiety accounted for 37% (r2) of the vari-
ance in depression and multicollinearity did not interfere with
the interpretation of these data.41
Second, to test if the results were biased by differences
between subjects who agreed or did not agree to participate at
T2, the analysis was repeated for all subjects who participated
at T1 (n = 146) using attachment, disease activity, and
depression scores collected at T1. The results were similar to
those reported for the T2 participants alone. In particular, the
correlation between disease activity and depression in each
tercile of attachment anxiety was as follows: low attachment
anxiety, r = 20.03, P = 0.84; moderate, r = 0.40, P = 0.004;
high, r = 0.46, P , 0.001. The correlation between disease
activity and depression in each tercile of attachment avoidance FIGURE 1. The correlation between UC disease activity and
was as follows: low attachment avoidance, r = 0.08, P = 0.60; depressive symptoms in groups defined by tercile split of
moderate, r = 0.19, P = 0.20; high, r = 0.42, P = 0.002. attachment anxiety (A) or attachment avoidance (B).

q 2005 Lippincott Williams & Wilkins 923

Maunder et al
statistical testing showed that a pattern consistent with a
moderating effect of attachment insecurity was present for
attachment anxiety and not for attachment avoidance. Specif-
ically, mean depressive symptom score was higher in the active
FIGURE 2. The correlation between disease activity and
depression in groups defined by a median split of attachment
anxiety and attachment avoidance.
FIGURE 3. Comparison of depression symptom score in sub-
jects with or without physician-observed signs of gut in-
flammation at high and low levels of attachment anxiety (A) or
attachment avoidance (B).
924
Inflamm Bowel Dis  Volume 11, Number 10, October 2005
disease group than in the inactive disease group when
attachment anxiety was high (P = 0.02) but not when attach-
ment anxiety was low (P = 0.47). For attachment avoidance, the
comparison of depressive symptoms between disease activity
groups was nonsignificant in both high and low avoidance
groups (high attachment avoidance, P = 0.11; low attachment
avoidance, P = 0.08).
DISCUSSION
This study shows that, in a population with mild to
moderately severe UC, there is a relationship between disease
activity and depressive symptoms and that this relationship is
moderated by the intensity of attachment insecurity. Among
those with insecure attachment, more severe disease is
associated with more severe depressive symptoms. Whereas
there are clinically significant depressive symptoms in some
people with secure attachment, these symptoms bear little or
no relationship to UC disease activity.
The moderating effect of attachment insecurity seems to
be primarily caused by attachment anxiety. The 2 dimensions
of attachment insecurity are correlated, so that individuals high
in attachment anxiety are also likely to be high in attachment
avoidance; however, attachment avoidance in itself does not
seem to increase the risk of concurrent elevation of disease
activity and depressive symptoms (Figs. 2 and 3).
This study has shown that attachment anxiety meets
all of the conditions of a moderating relationship except for
1 condition that was not tested. First, attachment anxiety has
been shown to be stable enough over time that it can be reliably
assumed to have been present before the occurrence of active
disease, because attachment anxiety has test–test stability of
r = 0.83, with tests separated by 7 to 37 months and because
there is no evidence that attachment anxiety changes when UC
disease activity changes. It bears emphasis that this analysis is
concerned with whether or not attachment anxiety is present
before a current episode of active disease and does not speak to
the longer-term question of a patient’s attachment style before
the onset of disease. Second, it is shown that there is no cor-
relation between attachment anxiety and disease activity. Third,
it is shown that the relationship between disease activity and
depression is stronger at higher levels of attachment anxiety.
The untested condition is that disease activity precedes
depression. If attachment anxiety moderates a causal relation-
ship between disease activity and depression, disease activity
must necessarily precede depression. This temporal order
would be consistent with previous studies.6–8 We consider the
alternative causal interpretation—that in the context of attach-
ment anxiety, depression provokes inflammatory activity—to
be less likely, but it is not ruled out by this study. Similarly,
the methodology of this study does not rule out alternative
explanations of the disease–depression relationship (such as
that each is caused by an unmeasured third factor).
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Inflamm Bowel Dis  Volume 11, Number 10, October 2005
An important implication of this result is that physicians
can identify the patients who are at greatest risk of depression
during active disease by identifying the patients who are high
in attachment anxiety. The behavioral patterns that are typi-
cally observed in attachment anxiety are described else-
where12,23,31,42,43 but can be briefly summarized. The typical
features of high attachment anxiety in adults include (1) a
sense of personal fragility and fear, (2) an expectation of aban-
donment, (3) dependency—a preference for remaining close
to others who could provide security, (4) anxious vigilance
regarding the proximity, responsiveness, and competence of
others, (5) persistent, explicit expressions of distress and re-
quests for help, which may take the form of symptom reports,
and (6) a vague and dramatic style of speaking that com-
municates emotional distress more effectively than it conveys
useful diagnostic information.
Previous research shows that patients with high attach-
ment anxiety tend to report physical symptoms that are not
explained by their underlying illness.14 Although the reasons
for this are not fully understood, it is thought that overreporting
of symptoms is the result of anxious vigilance toward one’s
inner sensations and a style of keeping other people close by
frequently emitting signals of distress.23 In this case, the dis-
tress signal is the report of a physical symptom, and the sig-
nificant ‘‘other’’ is the health care provider. This interpretation
is consistent with research that shows higher rates of health
care use among patients high in attachment anxiety.13
When high attachment anxiety is combined with high
attachment avoidance, a person experiences conflict between
the preference for proximity to others and apprehension about
the interpersonal risks associated with closeness. This com-
bination is designated the fearful attachment style.33,43,44 Pro-
totypically, fearful individuals display an attitude of anxious
interpersonal avoidance. They may appear shy or overly
cautious.33,43 Compared with people with high attachment
anxiety who are not also high in avoidance, fearful individuals
may have a less dramatic communication style and a marked
lack of assertiveness in making any requests of help.
This study may lead to further work directed toward
understanding the role of interpersonal factors in the course of
inflammatory bowel disease and other chronic diseases. First,
there is no reason to believe that the moderating relationship
studied here is specific to UC. Further study in Crohn’s disease
and other chronic illnesses is warranted. Second, the role of
interpersonal factors in the course of UC deserves further
study to determine if interpersonal factors have a causal effect
on the course of illness or are simply markers of a differential
risk of depression in the course of disease. If interpersonal fac-
tors affect disease course, interpersonal interventions, designed
to increase social support or resilience, may be indicated for
some individuals.
The methods of this study impose limitations on the
conclusions that can be made. First, the subjects studied were
q 2005 Lippincott Williams & Wilkins
Disease Activity and Depressive Symptoms in UC
experiencing mild to moderate severity UC. It is not known
if the same results would hold in a more severely ill popula-
tion. Second, subjects who were available and agreed to par-
ticipate at T2 were different than nonparticipants with respect
to age, duration of disease, and depressive symptoms. T2
participants were older, later in the course of their UC, and less
depressed. However, the evidence for a moderating effect is
essentially identical whether using T1 or T2 data and so this
possible bias does not seem to alter the evidence for modera-
tion by attachment anxiety. A further limitation is that this
study examines the risk that depressive symptoms will occur
when UC is active. Further research using diagnostic evalua-
tion is required to determine if this risk extends to a higher risk
of major depression.
It cannot be assumed that the relationship that has been
shown in this study is causal. However, because attachment
anxiety is theoretically modifiable through psychotherapy or
relationship experiences, a causal relationship is testable. If an
interpersonal factor moderates the disease–depression rela-
tionship, a trial of interpersonally focused psychotherapy to treat
depression in UC may be promising. Interpersonal psycho-
therapy for depression is a brief modality of therapy with strong
empirical support for efficacy in mild to moderate depres-
sion,45,46 which can be modified for use in medical popula-
tions,47 but which has not been evaluated in depression in UC.
In summary, a moderating effect of attachment anxiety
on a statistical relationship between disease activity and
depression was found, which may have clinical value and
implications for the treatment of depression in illness. Because
there is no reason to assume that the moderating effect of
attachment anxiety is specific to UC, efforts at replication in
other medical conditions are encouraged to determine the
extent to which this relationship is generalizable.
ACKNOWLEDGMENTS
The authors thank Drs. Mark Silverberg, Alvin Newman,
and Maria Cino for recruitment of subjects.
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