Implications of Attachment Theory and Reasearch fo


In this paper, we review the research literature on attachment and eating disorders and suggest a
framework for assessing and treating attachment functioning in patients with an eating disorder.
Treatment outcomes for individuals with eating disorders tend to be moderate. Those with attachment-
associated insecurities are likely to be the least to benefit from current symptom-focused therapies. We
describe the common attachment categories (secure, avoidant, anxious), and then describe domains of
attachment functioning within each category: affect regulation,interpersonal style, coherence of mind,
and reflective functioning. We also note the impact of disorganized mental states related to loss or
trauma. Assessing these domains of attachment functioning can guide focused interventions in the
psychotherapy of eating disorders. Case examples are presented to illustrate assessment, case formula-
tion, and group psychotherapy of eating disorders that are informed by attachment theory. Tailoring
treatments to improve attachment functioning for patients with an eating disorder will likely resultin
better outcomes forthose suffering from these particularly burdensome disorders.

During the past 30 years, attachmenttheory (Bowlby,1980)
has emerged as one ofthe mostimportant conceptualframe-
works for understanding affectregulation and human relation-
ships (Mikulincer & Shaver, 2007). Also, during that period,
research on eating disorders has been increasing (Theander.
2004). However, attachmenttheory is only recently being ap-
plied to research on eating disorders (e.g.,Illing, Tasca, Bal-
four, & Bissada, 2010). The goal ofthis practice review is to
conceptualize eating disordertreatment using attachmentthe-
ory, and to orient clinicians to use attachmenttheory forthe

psychological assessment, case formulation, and psychotherapy
ofindividuals with an eating disorder.
There are three main diagnostic categories of eating disorders,
namely, anorexia nervosa (AN), bulimia nervosa (BN). and eating
disorders not otherwise specified (American Psychiatric Associa-
tion [APA], 2000). AN is characterized by maintaining body
weight at or below 15% ofthe normal value, and an intense fear of
gaining weight. BN is characterized by recurrent binge eating,
followed by inappropriate compensatory behaviors (e.g., vomit-
ing). Eating disorders not otherwise specified is a category for
individuals who do not meet specific criteria for AN or BN but
who exhibit significant eating disorder symptoms (e.g., binge
earing with no purging,i.e., binge eating disorder[BED]). Eating
disorders occur predominantly in women, such that approximately
1 %-4% of adult women have a diagnosable eating disorder(APA,
2000). These individuals often sufferfrom comorbid psychiatric
disorders such as depressive, anxiety, personality, and substance
use disorders (Grilo, White, & Masheb, 2009). The mortality rate
for AN is the highest among all psychiatric disorders (Agras,
2001), and the eating disorders resultin very high personal and
economic burden (Grenon et al., 2010).