British Journal of Medical Psychology (2001), 74, 497–505 Printed in Great Britain 497

q 2001 The British Psychological Society

A ttachment in anorexia nervosa:

A transgenerational perspective
A nne Ward* , Rosalind Ramsay, Susan Turnbull, Miriam Steele,
How ard Steele and Janet Treasure
Eating Disorders Unit, Institute of Psychiatry, De Crespigny Park, London, UK

Both clinical and empirical studies suggest that insecure attachment is common in
eating disordered populations. Clinical studies have addressed mother–daughter
interactions, but there has been little empirical research into the mother’s own
attachment patterns and whether there might be intergenerational transmission of
these patterns. We aimed to examine the attachment status of patients with severe
anorexia nervosa and their mothers, using the ‘gold standard’ Adult Attachment
Interview (AAI). We predicted: (1) a high level of insecurity among the patients
(women with anorexia nervosa with or without bulimic behaviours); (2) that the
mothers would show a higher rate of insecurity than predicted by population norms;
and (3) that there might be attachment style associations within mother–daughter
pairs. Twenty consecutivein-patients with a DSM-IV diagnosis of anorexia nervosa were
interviewed using the AAI, as were 12 of their mothers. The mental state of daughters
was rated by experienced clinicians, and that of mothers by the Clinical Interview
Schedule (Revised). AAIs were transcribed and rated by expert raters. Nineteen (95%)
daughters and 10 (83%) mothers were rated insecure on the AAI. Of these, 15 (79%)
daughters and seven (70%) mothers were dismissive in type. We did not Žnd an
association between mothers’ and daughters’ attachment style. The incidence of
unresolved loss was high among the mothers (67%). Idealization scores were high
and reective functioning scores low in both mother and daughter groups. Women with
anorexia nervosa and their mothers commonly have a dismissive attachment style. Low
levels of reective functioning and high idealization scores are found in both groups,
and may be learned (or transmitted) from mother to daughter. A difŽculty in emotional
processing, exempliŽed by unresolved loss, may be transmitted to daughters, and act as
a risk factor for the development of anorexia nervosa.

Bruch described mother–infant feeding interactions and the related attachments in the
early 1970s, and also proposed that abnormal mother–daughter relationships underlie
the later development of eating disorders. She suggested that the mother’s own
difŽculties were projected onto the infant (Bruch, 1974). Formal application of attach-
ment theory to eating disorders has developed only recently, with somewhat confusing
results (reviewed by Ward, Ramsay, & Treasure, 2000). Only two studies to date have
used the ‘gold standard’ Adult Attachment Interview (AAI) in a clinical group of eating
disordered patients. Fonagy et al. (1996) used the AAI in an in-patient therapeutic
community, in which 14/82 patients had eating disorders. Of the 14 patients, 13 were
* Requests for reprints should be addressed to Dr Anne Ward, Consultant Psychiatrist in Psychotherapy, Psychotherapy
Unit, 3rd Floor, OPD, Maudsley Hospital, Denmark Hill, London SE5 8AZ, UK.
498 Anne Ward et al.
rated insecure, and 13/14 had problems with the resolution of loss or abuse. A more
recent study using the AAI in eating disordered in-patients suggests that restricting
anorexic and bulimic patients may adopt differing attachment stances, albeit both
insecure (Candelori & Ciocca, 1998). More generally, there is evidence that attachment
patterns are maintained across generations (Benoit & Parker, 1994; Fonagy, Steele, &
Steele, 1991; Steele, Steele, & Fonagy, 1996; van Ijzendoorn, 1995), suggesting a
transgenerational transmission of attachment security. The aim of this study was to
examine the attachment status of our in-patients and their mothers, and to test Bruch’s
hypothesis that abnormal patterns of attachment in mothers and daughters could be
relevant in eating disorders. We predicted (1) a high level of insecurity among the
patients (anorexic women with or without bulimic behaviours); (2) that the mothers
would show a higher rate of insecurity than predicted by population norms; and (3) that
there might be attachment style associations within mother–daughters pairs.

Methods

Participants
The setting was a tertiary referral centre for eating disorders. Participants were consecutive in-patients with a
DSM-IV diagnosis of anorexia nervosa and their mothers. In all, 28 patients were approached, and 24 agreed
to participate in the study. Of these 24, one patient withdrew during the study. In three cases, the tape-
recorder malfunctionedsuch that the interviews were unusable. Thus 20 patients were Žnally entered into the
study. Of 20 mothers, 12 agreed to participate. All participants were asked to complete the AAI. Mothers
completed the Clinical Interview Schedule (Revised) and a demographic and clinical history questionnaire.

Instruments
Adult Attachment Interview (AAI). The AAI is a semi-structured interview, which claims to ‘surprise the
unconscious’. It asks about childhood and current experienceswith attachmentŽgures, and about past trauma
in the form of loss or abuse (George, Caplan, & Main, 1985). The interviews are recorded and the transcribed
tapes coded. Participants are rated as secure or insecure with respect to attachment based primarily on the
coherence of their discourse. A secure participant (F) gives a balanced, fresh and thoughtful account,
integrating bad experiences as well as appreciating loving experiences. An insecure-dismissive participant
(D) presents her childhood as Žne and normal, idealizing attachment Žgures, but with no, or contradictory,
evidence to back up her statements. The insecure-preoccupied participant (E) is entangled with her
attachment Žgures, unable to rise above the experiences, angrily recounting recent offences or passively
conveying a nebulous sense of attachment difŽculties. If the disclosure reects a mixture of these insecure
strategies such that it cannot be placed in either one, it is described as cannot classify (CC). A Žfth
classiŽcation relates to the way loss or trauma is discussed. Breaks in the coherence of the discourse around
these topics pointing towards an unresolved (U) status. Because these phenomena are limited intrusions,
transcripts rated U are always coupled with a best-Žtting alternate classiŽcation (D/E/F/CC), that which
reects the predominant discourse style in the remainder of the interview.
Scores for probable experience (loving, rejecting, neglecting,role reversal and pressure to achieve) and state
of mind (idealization, derogation, involving anger, lack of recall, coherence of transcript, coherence of mind,
passivity of thought and fear of loss) are also generated from the interview, as is a score for reective
functioning. The probable experience and state of mind scales contribute to the overall classiŽcation, such
that, for example, a strongly ‘idealizing’ version of childhood points towards an insecure-dismissive stance,
whereas ‘involving anger’ points towards insecure-preoccupied. Reective functioning is a measure of the
participant’s capacity to ‘mentalize’, and involves both self-reective and interpersonal components. It is
rated on a scale from ± 1 to 9, where 5 is the most common rating in a high functioning ‘normal’ sample.
 Attachment in anorexia nervosa 499
The AAI has been thoroughly tested, and evidence for its reliability and validity is reviewed by van
Ijzendoorn and Bakermans-Kranenburg (1996).
In this study, the AAIs were classiŽed by two of the authors (HS and MS), both trained raters, who were
independent from the rest of the research group. Although theoretically blind to the mother/daughter status
of the interviews, in practice many of the accounts gave this away.

Clinical Interview Schedule (Revised) (CIS–R). We used the CIS–R to screen for psychiatric symptomatologyin
mothers. It is a self-administered computerized assessment for minor psychiatric disorder, which is a valid,
unbiased measure of psychiatric morbidity in primary care (Lewis, 1994). Participants are asked about
symptoms of depression, anxiety, panic, obsessive-compulsive disorders and phobias. The interview also
elicits ‘manifest abnormalities’ in the areas of depressive thinking and excessive bodily concern. A score of 12
or more indicates a clinically signiŽcant level of distress. ICD-10 diagnoses are generated, as well as
comments about speciŽc areas of concern, such as family or Žnancial worries.

Questionnaire. We included our own questionnaire for mothers, inquiring about a history of eating
disorders, drug or alcohol problems and whether they had ever seen a psychiatrist or psychologist (i.e.
items not covered by the CIS–R). Access to similar information for daughters was obtained from hospital
case notes.

Data analysis
Fisher’s exact test was used to compare various two-way classiŽcations between mothers and daughters (secure
vs. insecure, dismissive vs. non-dismissive, unresolved vs. resolved). Paired t tests were used to compare
probable experience and state of mind scores between the mother–daughter pairs. A variation of the t test,
based on means and standard deviations and written in SPSS syntax was used to compare our data with
published scores (Fonagy et al., 1996).

Results

Patients
All consenting patients were female; of those refusing, three were female and one was
male. Among the patients, the median age was 22 (range 15–46). Two patients were age
15, one was 16, and the rest were 18 or over. The mean body mass index on admission was
14.5 kg/m2 (SD = 2.5 kg/m2). Three patients had an admission BMI slightly greater than
17.5—approximately equivalent to body weight 15% below expected (17.7, 17.9 and
19.0)—and one (BMI = 17.7) still had periods. However, all three had past episodes of
anorexia nervosa when they had fulŽlled DSM criteria. The median duration of illness was
4.3 years (range = .3–32), and 12 patients had had previous in-patient treatment for an
eating disorder. Six of the 20 patients had a restricting pattern at the time of admission,
and 14 in addition either binged, vomited or took laxatives.

Mothers
Demographic and Psychiatric History Questionnaire. The median age of mothers was 49 years
(range = 40–81). None had a history of eating disorder. Five mothers had sought
psychiatric/psychological help at some point in the past. Three had a history of depression
unrelated to their daughter’s eating disorder, one recorded depression as a result of her
daughter’s difŽculties, and one had seen a counsellor who ‘told me to sort myself out
before I could help my daughter’.
500 Anne Ward et al.
CIS–R. On the CIS–R, Žve of the 12 mothers (42%) scored 12 or over, generating four
ICD-10 diagnoses (moderate depression ´ 2, mixed panic disorder, and mixed anxiety/
depression). The Žfth mother scored 16, but no ICD-10 diagnosis was generated. Of
the Žve mothers who had received, or were receiving, psychological or psychiatric
help, four were in the group with high CIS–R scores. Although our numbers were too
small to make statistical comparison with published rates of ‘caseness’ meaningful,
this level of distress has clinical signiŽcance, both for families and for involved
professionals.

Adult Attachment Interviews

Patients. Of the 20 patients, 15 (75%) were rated dismissive (D), four (20%) preoccupied
(E), and one (5%) secure (F). This compares to 24% D, 18% E and 58% F in a meta-
analysis of non-clinical women (van Ijzendoorn & Bakermans–Kranenburg, 1996). A
goodness-of-Žt test shows that the two distributions are signiŽcantly different
(x2 = 157; p < .001). Mean (SD) scores for patients’ probable experience, state of
mind and reective functioning are shown in Table 2. In four cases, there was insufŽcient
information for the rater to assign an unresolved (U) score (in three cases for potential
abuse, and in one for loss). Of the remainder, 8/16 interviews (50%) were classiŽed as U.
Scores of over 5 for loss or trauma are automatically rated U, whereas a score of 5 allows
the rater a U or non-U placement. If we include scores of 5 and over (i.e. no signiŽcant
evidence of resolution), 10/16 (63%) daughters were in this category. Using this cut-off
point, three patients were unresolved with respect to abuse, Žve with respect to loss and
an additional two with respect to both.

Mothers. Of the 12 mothers, seven (58%) were dismissing, one (8%) preoccupied and two
(17%) secure. Two (17%) were rated cannot classify. Using the next best Žtting
classiŽcation for the two CC cases (1E, 1D) again allows comparison with van
Ijzendoorn’s meta-analytic norms (24% D, 18% E, 58% F). A goodness-of-Žt test
shows the distribution among mothers to be signiŽcantly different (x2 = 103, p < .001).
Mean (SD) scores for mothers’ probable experience, state of mind and reective
functioning are shown in Table 2. Eight (67%) mothers were rated unresolved with
respect to loss, and 10 (83%) had scores of 5 or over on this scale, all related to loss. In one
case, there was insufŽcient information to rate for potential abuse, but this mother was
already U with respect to loss.

Mother–daughter classiŽcations
Numbers were too small to permit a chi-squared analysis. Using Fisher’s exact test, no
signiŽcant relationships were found.

Scale comparison with published data

Only one other published study gives AAI probable experience and state-of-mind scores
for eating disordered patients (Fonagy et al., 1996). In this study, eating disordered
 Attachment in anorexia nervosa 501
Table 1. Adult attachment classiŽcations vs. diagnosis
Daughter Mother
Daughter’s
Number D/E/F/CC U D/E/F/CC U illness
1 F5 U Ds3 U ANBP
2 Ds3 U Ds1 U ANBP
3 Ds3 * – ANBP
4 Ds1 * CC U ANR
5 Ds1 E1 U ANR
6 Ds1 Ds3 ANR
7 Ds1 – ANBP
8 Ds1 * Ds1 U ANBP
9 E2 U CC U ANBP
10 Ds1 – ANBP
11 Ds3 U Ds3 U ANBP
12 Ds1 – ANBP
13 Ds3 F1 U ANBP
14 E3 U – ANBP
15 Ds1 – ANR
16 Ds1 U Ds1 ANBP
17 E1 – ANBP
18 Ds2 U – ANBP
19 E1 U F3a ANR
20 Ds3 * Ds1 ANR
Notes: Ds = dismisive; E = preoccupied; F = secure; CC = cannot classify; U = unresolved; numbers 1–5 and letters a/b
represent subcategories within each classiŽcation; ANBP = anorexia nervosa (binge/purge); ANR = anorexia nervosa
(restricting); * = insufŽcient information to rate for U/non-U.

patients differed signiŽcantly from other psychiatric subgroups in their idealization

(higher) and reective functioning (lower) scores. Only means (SDs) are available for
comparison. Using t tests based on means (SDs), and a signiŽcance level of .05, we
compared (1) our ED patient scores with the published ED scores; (2) our mothers’ scores
with those of the psychiatric in-patients; and (3) our mothers’ scores with those of the
controls. Our ED patients differed signiŽcantly from the published ED group on the
coherence (lower than published group) and derogation (higher than the published
group) scales only. Our mothers had signiŽcantly higher idealization and lower reective
functioning scores than the psychiatric in-patients, similar to those of the ED groups.
They differed signiŽcantly from psychiatric in-patients in the expected direction on the
following scales : loving (higher), rejecting (lower), neglecting (lower) and involving
anger (lower). Compared to controls, our mothers had signiŽcantly different loving
(lower), rejecting (higher) and neglecting (higher) scores. They were also signiŽcantly
more idealizing, less coherent and had less reective functioning than controls.
This can be summarized by saying that our ED patients presented a similar picture
to that of the published ED group, which was distinguished by high idealization and
low reective functioning scores. Our mothers had probable experience scores some-
where between those of the in-patient psychiatric group and those of controls.
However, like the ED patients and their own ED daughters, mothers’ scores for
502 Anne Ward et al.
Table 2. Mean (SD) Adult Attachment Interview Scale scores for patients, mothers and published
data
Our Our Psychiatric Control Eating
patients mothers in-patients group disorder
(N = 20) (N = 12) (N = 82) (N = 85) (N = 14)
Probable experience
Loving parents 3.2 (1.3) 3.9 (1.6)BCC 2.7 (1.5) 5.5 (1.8) 2.3 (1.6)
Rejecting parents 5.5 (2.3) 4.4 (1.8)BCC 5.9 (2.2) 3.0 (1.5) 5.5 (2.2)
Neglecting parents 5.5 (2.0) 5.0 (1.8)BC 5.9 (2.0) 3.6 (1.7) 6.4 (2.0)
Role reversal 3.1 (2.2) 2.0 (1.5) 2.7 (1.6) 1.9 (1.2) 3.1 (1.6)
Pressure to achieve 3.6 (2.3) 2.5 (1.7) 2.5 (1.9) 2.6 (1.3) 3.1 (1.9)
State of mind
Idealization of parents 3.8 (2.4) 4.4 (1.2)BBCC 2.6 (1.7) 3.0 (1.1) 4.1 (1.6)
Derogation of parents 3.4 (3.0)A 2.2 (1.7) 2.1 (1.3) 2.0 (1.0) 1.9 (1.3)
Involving anger 2.2 (1.9) 1.6 (1.0)BB 4.1 (1.8) 2.2 (1.3) 3.4 (1.9)
Lack of recall 5.7 (2.3) 4.1 (2.3) 4.1 (1.8) 3.6 (1.3) 4.4 (1.9)
Coherence of mind 2.3 (1.1)AA 3.2 (1.8)CC 4.1 (1.6) 5.5 (1.4) 4.1 (1.6)
& transcript
Passivity of thought 2.1 (1.6) 2.3 (2.0) 3.0 (1.9) 2.1 (1.1) 2.9 (1.9)
Fear of loss 1.1 (.3) 1.7 (1.6) 1.6 (1.2) 1.3 (.6) 1.5 (1.2)
Reective self 2.4 (1.6) 2.4 (1.3)BCC 3.7 (1.8) 5.2 (1.5) 2.8 (1.7)
Notes: A = our patients vs. published ED patients (A = p < .05; AA = p < .01); B = our mothers vs. published psychiatric
patients (B = p < .05; BB = p < .01); C = our mothers vs. published controls (C = p < .05; CC = p < .01).

idealization and reective functioning were more extreme than those of the psychiatric
in-patients in general.

Discussion
Our Žrst hypothesis was conŽrmed in that we found a 95% level of insecure attachment
in our sample of patients with anorexia nervosa (75% D, 20% E). The majority of
mothers also had insecure attachments (58% D, 8% E and 17% CC). In fact, only one
patient and two mothers received secure ratings, and of these three, two were unresolved
with respect to loss. The distribution in both groups was signiŽcantly different from that
of published norms (van Ijzendoorn & Bakermans-Kranenburg, 1976). The frequency of
unresolved loss of trauma was unexpected and striking, particularly among the mothers,
as was the Žnding of signiŽcant psychiatric morbidity in almost half of that group. The
patient subscale scores were broadly similar to published data on eating disordered
patients. In particular, there were low levels of reective functioning. Interestingly, the
subscale scores in the mothers were closer to the eating disorder groups than to those of
published controls. However, there was no signiŽcant association found between the
attachment classiŽcations of mother–daughter pairs, but the power of the study to test
this hypothesis was limited.
The study has other limitations, such as the absence of a non-eating disordered
psychiatric control group. Although we have compared our results to published data,
rated by the same raters, and which include psychiatric controls (Fonagy et al., 1996), it
 Attachment in anorexia nervosa 503
could be argued that our Žndings relate to psychiatric illness in general rather than to
anorexia nervosa in particular. Another limitation is the restriction of the study to cases
severe enough to need admission, so that it cannot be generalized to all those with
anorexia nervosa.
The preponderance of dismissive attachment styles was a marked feature of the
analysis, both of the patients with anorexia nervosa and their mothers. The dismissive
stance represents a defensive turning away from potentially painful emotional material,
similar to the anorexic’s denial of hunger. There is a sparsity of speciŽc attachment-linked
recall; amidst global assurances that everything was Žne and normal, evidence to the
contrary may also emerge. This links with research from another Želd showing that,
relative to healthy controls, patients with a diagnosis of eating disorder were slower to
generate speciŽc autobiographical memories (i.e. an actual incident) to emotional cue
words. Furthermore, in the eating disordered group, self-reported levels of parental abuse
correlated with the tendency to produce general (rather than speciŽc) memories to
negative cue words (Dalgleish et al., 2000). The authors argue that this represents a
defensive cognitive processing bias that is itself related to prior adverse experiences. It is
interesting to note the convergence between the studies deriving from two different
theoretical standpoints.
In terms of the older clinical literature, a dismissive stance would limit a mother’s
response to an infant’s emotionally based attachment needs, particularly when these stir
up negative feelings. Infants of such mothers may be adequately cared for physically, and
even attended to emotionally up to a point, but certain experiences (mainly negative)
would be likely to remain unprocessed. In Bruch’s terms, such a mother superimposes her
own needs on those of her infant, who then grows up unable to differentiate its own
needs/wants. Such an infant remains dependent on the mother to supply a sense of self,
yet having to defend against the mother’s intrusiveness. Bruch (1974) describes the
evolution of such an infant into the eating disordered adolescent. Thus, our Žndings
provide a plausible empirical link to this literature.
We found a high rate of unresolved status (U) with respect to loss or trauma (50% in
patients and 67% in their mothers). This compares to 19% in a meta-analysis of non-
clinical women (van Ijzendoorn & Bakermans–Kranenburg, 1996). The high rates
among patients may reect the often highly traumatic attachment experiences in
psychiatric groups, which exceed the norm for community samples. In our study, for
example, seven patients (35%) recalled some form of abusive experience. The higher rate
of U with respect to loss among the mothers was unexpected. One previous study showed
a high rate of U (44%) in mothers of children with oppositional disorder, but these
children were still preschoolers (DeKlyen, 1992). In addition, the authors did not specify
whether loss or trauma was involved. To our knowledge, there is no literature on the
incidence of unresolved loss or trauma among parents of adult/adolescent psychiatric
patients, and our high rate was unexpected clinically.
An excess of severe obstetric loss prior to the daughter’s birth has been shown in
families with an adolescent anorexic daughter (Shoebridge & Gowers, 2000). In addition,
Wentz-Nilsson, Gillberg, and Rastam (1998) found signiŽcantly more deaths among the
Žrst-degree relatives of teenagers with anorexia nervosa than among controls. The
relevant variable may be how those losses are processed within the family. Shoebridge
and Gowers record high levels of parental concern in the parents of later anorexic
504 Anne Ward et al.
adolescents and suggest that this may derive, in part, from abnormal grief reactions.
Interestingly, a semi-projective test applied to eating disordered patients found that they
did not appear to distinguish cognitively between brief and more permanent leavings
(Armstrong & Roth, 1989). It would be important to repeat this study with other
psychiatric groups to tease out the speciŽc contribution to eating disorders. However, a
theme of unresolved loss would be consistent with the older clinical literature, which
emphasizes early separation difŽculties in the aetiology of anorexia nervosa.
On a practical level, we found a clinically meaningful level of psychological distress
among the mothers, which may or may not be related to unresolved loss, but which
deserves attention in its own right. In a comparison with carers of psychotic patients,
carers of offspring with anorexia nervosa had higher scores on the GHQ, and experienced
higher levels of difŽculties in all areas measured, apart from access to services (Treasure
et al., 2000). In addition, it may be that such distress would activate an unresolved
strategy which would otherwise lie dormant, particularly in view of the life-threatening
nature of severe anorexia nervosa. Although there was no association between psycho-
logical distress and unresolved status in the mother, our numbers were too small to
discount this hypothesis. It would be a fruitful area for further study.
It is of interest to compare our subscale scores with the only other published subscale
scores for eating disordered patients (Fonagy et al., 1996, Table 2), particularly as the
same raters (HS and MS) scored both these sets of interviews. Psychiatric in-patients
(N = 82) in a therapeutic community (TP) setting were compared to normal controls
(N = 85) on various measures, including the AAI. The in-patient group included 14
patients (17%) with an eating disorder. In the published study, eating-disordered
patients differed signiŽcantly from other psychiatric subgroups in their idealization
scores (higher) and in their level of reective functioning (lower). Our eating-disordered
patients were similar to the published group on these two scales. These Žndings are
consistent with other work, showing that a subgroup of anorexic patients may have
difŽculty identifying and communicating feeling states (Rastam, Gillberg, Gillberg, &
Johansson, 1997).
Both the Žndings and the limitations of this study suggest avenues for further research.
A similar study could be carried out with larger numbers of mother–daughter pairs,
looking for transgenerational similarities. The investigation could be broadened to
include fathers, as attachment theory in general accords fathers a greater role than some
more traditional theories. The issue of unresolved loss and trauma, and how this is
internalized by the next generation, is of interest not just to eating-disorder specialists,
but to therapists in general. Finally, this study has implications for clinicians, working
either individually or systemically. Our Žndings suggest that not only is the dismissive
stance important, but that unresolved loss may be more common in these families than is
habitually recognized.

A cknow ledgements
We would like to thank Dr Sabine Landau, Dept of Biostatistics and Computing, Institute of Psychiatry, for
helpful statistical advice; and Dr Maureen Marks, Psychotherapy Unit, Maudsley Hospital, for helpful
comments on earlier drafts of the article.
 Attachment in anorexia nervosa 505
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Received 14 December 2000; revised version received 21 May 2001