Pain 123 (2006) 146154

www.elsevier.com/locate/pain

Adult attachment, anxiety, and pain self-ecacy as predictors

of pain intensity and disability
a,*
Pamela Meredith , Jenny Strong a, Judith A. Feeney b

a
Division of Occupational Therapy, The University of Queensland, Australia
b
School of Psychology, The University of Queensland, Australia

Received 22 September 2005; received in revised form 10 February 2006; accepted 21 February 2006

Abstract

Pain self-ecacy and anxiety have each been shown to contribute substantially to pain intensity and pain-related disability.
Although adult attachment theory has been related separately to chronic pain, anxiety, and self-ecacy, it has not before been inves-
tigated with either pain self-ecacy or anxiety in the context of chronic pain. This study investigated the interrelations between these
aspects of the chronic pain experience and their relative contributions towards pain intensity and disability. A clinical sample of 152
chronic pain patients participated in this study, completing self-report measures of attachment, self-ecacy, pain intensity, and dis-
ability, prior to attending a multidisciplinary pain clinic. Results revealed that fearful and preoccupied (anxious) attachment cate-
gories were associated with low pain self-ecacy, while high scores on the attachment dimension of comfort with closeness were
linked with high pain self-ecacy, particularly for males. Insecure attachment (whether dened in terms of categories or dimensions)
was related to higher levels of anxiety. Pain self-ecacy proved a stronger predictor of pain intensity than did anxiety and was a
stronger predictor of disability than pain intensity or anxiety. In addition, comfort with closeness moderated the associations
between pain self-ecacy and disability, pain self-ecacy and pain intensity, and anxiety and disability. Together, these ndings
support the value of adopting an attachment theoretical approach in the context of chronic pain. Treatment considerations and
future research directions are considered.
2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Keywords: Adult attachment theory; Pain self-ecacy; Anxiety; Disability; Pain intensity; Chronic pain

1. Introduction will be considered stressful if the individual both

The importance of positive pain self-ecacy for suc-
cessful adaptation to chronic pain is well documented
(Arnstein, 2000; Ayre and Tyson, 2001; Turk and Oki-
fuji, 2002). Conversely, the maladaptive impact of high
levels of anxiety for those in pain has been equally well
established (McCracken et al., 1999; Edwards et al.,
2003). These two mechanisms are theoretically linked.
According to the theory of stress and coping, an event
*
Corresponding author. Tel.: +61 7 3365 2652; fax: +61 7 3365
1622.
E-mail address: p.meredith@uq.edu.au (P. Meredith).
appraises it as threatening and believes they are ill
equipped to cope with the threat (Cohen and Wills,
1985). This low self-ecacy then increases anxiety, with
damaging physiological sequelae (Bandura et al., 1987).
Adult attachment theory has been heralded as a
developmental model for chronic pain (Mikail et al.,
1994). It has also been described as a theory of aect
regulation (Feeney and Noller, 1996) and linked devel-
opmentally with self-ecacy (Feeney, 2004). Attach-
ment theory holds that interpersonal experiences from
birth onwards contribute to the development of relative-
ly stable internal working models (IWMs; mental mod-
els of the self and others that predict behavior, thoughts,

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.2006.02.025
 P. Meredith et al. / Pain 123 (2006) 146154 147

and feelings, Bowlby, 1969/1997). Threat appraisals Table 1

mobilize IWMs dependent on attachment security. Demographic details
Secure IWMs have been linked with more positive social Variable N = 152 %
self-ecacy (Wei et al., 2005) and career decision-mak- Location
ing self-ecacy (Wolfe and Betz, 2004), and lower levels More than two locations 45 29.6
of anxiety (Moreira et al., 2003). Insecure-anxious Lower back and legs 85 55.6
Upper back and arms 14 9.2
attachment has been linked with decreased social self-ef- Other (head, viscera) 7 4.6
cacy (Wei et al., 2005) and high levels of anxiety. Inse- Missing 1 0.7
cure-avoidant attachment has been positively linked
Gender
with denial of aect, including anxiety (Weems et al., Male 88 57.9
2002), and is theoretically associated with increased Female 63 41.4
self-ecacy based on a positive sense of self (Simpson Missing 1 .7
and Rholes, 2002). Adult attachment has not yet been Marital status
investigated with either pain self-ecacy or anxiety in Married/de facto 101 66.4
the context of chronic pain. Divorced 15 9.9
Recent evidence in the chronic pain literature demon- Separated 4 2.6
Never married 29 19.1
strates associations between attachment style and dis-
Widowed 2 1.3
ability, health care utilization, depression, and Missing 1 0.7
catastrophizing (Ciechanowski et al., 2003; Meredith
Education
et al., in press; Rossi et al., 2005). The present study Less than Junior (10 years) 21 13.8
sought to investigate the relative contributions of adult Junior (10 years schooling) 46 30.3
attachment, pain self-ecacy, and anxiety towards per- Senior (high school graduate) 32 21.1
ceptions of pain intensity and pain-related disability. TAFE (technical or trade certicate) 35 23
Establishing links between these elds extends existing University/College Graduate 14 9.2
Missing 4 2.6
research, lends support to proposals of the utility of
adult attachment theory as a developmental framework Employment
Full-time 31 20.4
for chronic pain, and may suggest avenues for treatment
Part-time 7 4.6
beyond present cognitive-behavioral approaches. Unemployed 37 24.3
Retired 11 7.2
Sick leave 63 41.4
2. Research questions
Missing 3 2

First, low pain self-ecacy and high anxiety were Categorical (RQ) attachment
Secure 48 31.6
expected to be associated with insecure-anxious attach- Fearful 27 17.8
ment, while the reverse was expected to be true for Preoccupied 16 10.5
secure and avoidant attachment. Second, it was expect- Dismissing 34 22.4
ed that pain self-ecacy and anxiety would predict a Missing/unusable 27 17.8
substantial portion of variance in pain intensity and
disability. Because of inconsistent and limited research 3.2. Procedure
exploring associations between attachment style and
pain intensity and disability, no predictions were made Over a 14-month period, the principal investigator attended
in this regard. Finally, because dierent levels of self- two multidisciplinary chronic pain rehabilitation centers on
ecacy and anxiety are believed to be associated with the rst day of each new program. The study was explained,
dierent attachment styles and dimensions, the third and information sheets and consent forms were distributed
question explored the ability of attachment variables according to the Institutional Ethical Review Approved Proto-
cols. Consent was obtained to access data on le, and addition-
to moderate the empirically established eects of pain
al measures were administered.
self-ecacy and anxiety on disability and pain intensity.
3.3. Measures
3. Methods
3.3.1. Pain Self-Ecacy Questionnaire (PSEQ, Nicholas, 1994)
3.1. Participants The PSEQ is a measure of generalized pain self-ecacy
beliefs. Patients indicate how condent they are that they
Of approximately 320 individuals approached, 152 partici- can perform a range of activities despite the pain on a 7-point
pants were enlisted in this study on the rst day of a rehabili- scale (0 = not at all condent to 6 = completely condent).
tation program at one of two metropolitan chronic pain Sample items include I can enjoy things, despite the pain
rehabilitation centers. Demographic information is reported and I can still accomplish most of my goals in life, despite
in Tables 1 and 2. the pain. Internal consistency in this study was .93.
148 P. Meredith et al. / Pain 123 (2006) 146154

Table 2 varimax rotation. The relationship anxiety dimension consist-

Descriptive statistics for continuous variables ed of 23 items (a = .92), while the comfort with closeness
Variable Mean SD Minimum Maximum dimension comprised 10 items (a = .82). The latter item was
Age 38.81 12.36 18 82
named comfort with closeness rather than avoidance of close-
Duration of pain 3.68 6.85 2 months 34 years ness due to the large number of items reecting positive char-
Secure 3.99 2.16 1 7 acteristics. Sample items include: I worry a lot about my
Fearful 3.38 2.08 1 7 relationships (anxiety) and I feel comfortable depending
Preoccupied 2.78 1.92 1 7 on other people (comfort). It should be noted that the anxiety
Dismissing 3.92 1.96 1 7 dimension reects anxiety over relationships rather than anx-
ASQ anxiety 68.53 20.69 23 126 ious aect, while attachment avoidance (or comfort) relates
ASQ comfort 40.97 8.28 11 60 to relationships with others. These dimensions do not refer
Pain self-ecacy 28.29 13.31 0 54 directly to coping or emotive constructs previously explored
Anxiety 11.10 10.30 0 42
in the pain literature.
Pain intensity 5.39 1.78 1.75 10
Disability 41.31 13.51 12 78
3.3.5. Visual Analogue Scales (VAS, Turk and Melzack, 2001)
This common technique for measuring pain intensity
involves a series of four 10-cm horizontal lines anchored at
3.3.2. Depression Anxiety Stress Scales 21 (DASS21, Lovibond each end, and labeled no pain at one end, and pain as
and Lovibond, 1993, 1995) bad as it can be at the other. A mark is made on each line
This measure is a brief measure of the 42 item DASS and at the point corresponding to level of pain now, highest
consists of 21 questions exploring negative emotions experi- level of pain, lowest level of pain, and average pain over the
enced over the past week. Only the 7 questions relevant to last week. The length of these lines is then measured in
the anxiety scale are considered here. Questions are scored centimeters from the no pain end, as an indicator of pain inten-
on a four-point scale (0 = did not apply to me at all to sity. This result is averaged to obtain an overall pain intensity
3 = applied to me very much or most of the time). Internal score.
consistencies, reliability, temporal stability, convergent and
discriminant validity, and consistent factor structure have been 3.3.6. Oswestry Disability Index (Fairbank et al., 1980;
established (Lovibond and Lovibond, 1993; Brown et al., 1997; Fairbank and Pynsent, 2000; Roland and Fairbank, 2000)
Crawford and Henry, 2003). Factor analyses have also con- This index has become one of the most frequently used
rmed the three-scale structure of the 21-item DASS (Clara outcome measures of function in those with chronic back
et al., 2001). The alpha reliability for the anxiety scale in the pain. A wide range of reliability and validity data has been
present study was .86. reported (see Fairbank and Pynsent, 2000). The index
explores the functional impact of pain in 10 areas: pain relief,
3.3.3. The Relationship Questionnaire (RQ, Bartholomew and personal care, lifting, walking, sitting, standing, sleeping, sex
Horowitz, 1991) life, social life, and traveling. Scores are presented as a per-
This questionnaire consists of four paragraphs giving rise to centage disability. Alpha reliability for the present study
both categorical and continuous data. The categorical measure was .80.
is a forced-choice measure whereby participants select one of
the four paragraphs indicating their attachment style as secure, 4. Results
preoccupied (anxious), fearful (anxious and avoidant), or
dismissive (avoidant). It should be noted that categorical RQ 4.1. Statistical analyses
data were deemed unusable if participants selected more than
one of the paragraphs. The continuous measure, in which indi-
Results were analyzed using SPSS version 13.0.
viduals indicate the extent to which they resemble each of the
four attachment styles on a 7-point scale (1 = not like me at all
Missing data resulted in exclusion of some cases from
to 7 = very much like me), gives rise to four continuous scales. some analyses. Frequency and descriptive data are
The RQ has demonstrated adequate predictive validity and reported in Tables 1 and 2. No outliers were detect-
testretest reliability, and is a widely used measure of ed. Five skewed variables were identied: age, preoc-
attachment (Scharfe and Bartholomew, 1994; Herzberg et al., cupied attachment, anxiety, and pain duration were
1999). positively skewed, while comfort with closeness was
negatively skewed. The former four variables were
3.3.4. Attachment Style Questionnaire (ASQ, Feeney et al., transformed using logarithmic transformations, while
1994) comfort with closeness was reected and logarithmi-
This is a 40-item self-report measure of adult attachment cally transformed. Findings using transformed vari-
style. Items are rated on a 6-point scale (1 = totally disagree
ables did not vary substantially from those using
to 6 = totally agree). Two dimensions (relationship anxiety
and avoidance of closeness) have consistently been identied
original variables hence results using original vari-
using this measure (Feeney et al., 1994; Alexander et al., ables are discussed. Where regression analyses were
2001). The authors have reported acceptable internal consis- used, stepping method criteria were minimized to
tency and testretest reliability. In the present study, two sim- .01 on entry, and .02 on removal to decrease the risk
ilar dimensions were identied using factor analysis with of a Type I error.
 P. Meredith et al. / Pain 123 (2006) 146154 149

4.2. Comparisons between consenting and non-consenting Using a series of ANOVAs, gender, marital status,
individuals education, current employment, and location of pain
were each explored as independent variables in predic-
Statistical comparisons between those consenting to tion of the six continuous attachment variables. ASQ
participate and those not granting consent were not pos- comfort was signicantly associated with gender
sible. Nevertheless, it was possible to compare demo- (F (1, 142) = 5.8, p = .02), revealing that females were
graphic details of the sample obtained from each more comfortable with closeness (M = 43) than males
rehabilitation program with program statistics (see (M = 39.6), who were more avoidant. ASQ comfort
Table 3). This visual comparison suggests that, although was also associated with employment status
broadly representative of the participants attending the (F (4, 137) = 2.5, p = .04). According to post hoc Bonfer-
two rehabilitation programs, females and those in pain roni tests, the dierence between means of those
for a somewhat longer period may have been over-rep- employed full-time (M = 37.4) and those on sick leave
resented in the sample obtained for this study. (M = 42.6) almost reached signicance (p = .065), indi-
cating that those on sick leave were somewhat more
4.3. Associations between attachment, demographic, and comfortable with closeness than those working full-time.
medical variables RQ preoccupied attachment predicted marital status
(F (3, 139) = 5.2, p = .002), with never married partici-
A range of analyses were carried out to explore asso- pants reporting signicantly higher levels of preoccupied
ciations between attachment and any of the demograph- attachment (M = 4) compared with married participants
ic and medical variables. Correlations between (M = 2.5, p = .001). Neither location of pain nor educa-
continuous attachment variables and age, duration of tion was signicantly related to any of the attachment
pain, pain intensity, and disability revealed only one sig- variables.
nicant result secure attachment was negatively corre- A series of v2 analyses were conducted with RQ
lated with duration of pain (see Table 4). Similarly, a attachment category as the independent variable and
series of ANOVAs revealed no associations between categorical demographic variables as dependent vari-
these demographic and medical variables and RQ cate- ables. The only signicant association was with gender
gorical attachment. (v2 = 11, df = 3, p = .01), with almost half (47.2%) of
the female participants reporting a secure attachment
style compared with 31.9% of males. More of the
Table 3
Comparison between demographic data obtained in this study and females were fearful (28.3% compared to 16.7%), while
data from respective rehabilitation centers more of the males were preoccupied and dismissing
Variable Center 1 Center 2 (19.4% and 31.9%, respectively) compared to females
(3.8% and 20.75%). Because of the signicant associa-
Obtained Center Obtained Center
average average tions with attachment, employment status, marital sta-
tus, gender, and duration of pain, these variables were
Gender
Male 65% 75% 40% 52% included in further analyses. Because inclusion of dura-
Female 30% 25% 60% 48% tion of pain, employment, and marital status consistent-
Age 35.8 years 38.1 years 43.6 years 43.7 years ly revealed no signicant results, these details are not
Pain chronicity 11 months 6 months 8.2 years 7.5 years presented.

Table 4
Intercorrelations between variables
Variable Secure Fearful Preoccupied Dismissing Att comfort Att anxiety Pain VAS Self-ecacy Anxiety Disability
Fearful .17*
Preoccupied .06 .38***
Dismissing .004 .07 .03
Att comfort .43*** .29*** .14 .06
Att anxiety .34*** .36*** .54*** .01 .33***
Pain VAS .03 .14 .10 .004 .15 .05
Self-ecacy .07 .06 .06 .13 .30*** .14 .44***
Anxiety .16 .18* .18* .06 .24** .39*** .36*** .40***
Disability .05 .08 .01 .11 .03 .11 .45*** .56*** .33***
Duration .18* .004 .06 .06 .16 .01 .23** .01 .32*** .12
Age .04 .01 .03 .01 .02 .07 .24** .05 .15 .13
*
p < .05.
**
p < .01.
***
p < .001.
150 P. Meredith et al. / Pain 123 (2006) 146154
4.4. Associations between attachment categories, pain
self-ecacy, and anxiety
In order to determine associations between RQ
attachment categories, pain self-ecacy, and anxiety,
as predicted in Hypothesis 1, several two-way ANOVAs
were performed, with attachment category and gender
as independent variables. None of the main eects for
gender were signicant. A signicant main eect was
obtained for attachment with pain self-ecacy as the
dependent variable (F (3, 119) = 2.8, p = .04). Although
post hoc Bonferroni tests were not signicant, inspection
of the means suggested that self-ecacy scores for
secure and dismissing styles (M = 30.2 and 30.7) were
higher than for fearful and preoccupied styles
(M = 23.9 and 22.8). A signicant main eect for attach-
ment was also obtained with anxiety as the dependent
variable (F (3, 117) = 5.23, p = .002). Those with secure
attachment (M = 7.11) indicated signicantly lower lev-
els of anxiety than those reporting dismissing attach-
ment (M = 15.1, p = .004). Although not reaching
signicance, mean anxiety scores for those selecting pre-
occupied and fearful attachment categories were similar
to those of the dismissing individuals.
4.5. Associations between continuous attachment
variables, pain self-ecacy, and anxiety
Additional correlations were calculated in order to
explore relationships between continuous RQ attach-
ment ratings, ASQ attachment dimensions, pain self-ef-
cacy, and anxiety (see Table 4). Of the attachment
variables, only comfort with closeness was related to
pain self-ecacy. As expected, the three anxious attach-
ment variables (fearful, preoccupied, and anxiety over
relationships) were positively associated with anxiety,
while comfort with closeness was negatively linked with
anxiety. When these correlation analyses were repeated
for males and females separately, the signicant result
between comfort and self-ecacy was strengthened for
males (r = .41, p < .001) and was no longer signicant
for females. In addition, a signicant negative correla-
tion between males fearful attachment and self-ecacy
was identied (r = .25, p = .02).
4.6. Predicting disability and pain intensity
Hypothesis 2 suggested that pain self-ecacy and
anxiety would predict disability and pain intensity. A
regression analysis with anxiety and pain self-ecacy
as independent variables, and including age, gender,
and duration of pain as covariates, revealed a highly sig-
nicant overall result for average pain intensity
(F (5, 116) = 9.46, p < .001). All covariates were insignif-
icant and, in order to improve degrees of freedom, the
analysis was repeated with these variables removed
(F (2, 119) = 18.02, p < .001; anxiety t = 2.40, p = .02,
pain self-ecacy t = 4.03, p < .001). Together, anxiety
and pain self-ecacy accounted for 22% of the variance
in pain intensity.
A similar regression analysis was conducted for dis-
ability, with anxiety and pain self-ecacy as indepen-
dent variables, and again incorporating age, gender,
and duration of pain as covariates. A highly signicant
result was revealed (F (5, 96) = 9.27, p < .001). Again,
in order to improve degrees of freedom, non-signicant
covariates were removed (F (2, 99) = 22.73, p < .001;
pain self-ecacy t = 4.03, p < .001). Pain self-ecacy,
as the unique predictor, described 30% of the variance in
disability. Incorporating pain intensity with self-ecacy
as the independent variables had little eect on the over-
all signicance (F (2, 89) = 21.35, p < .001) and together
these variables explained 30.9% of the variance in dis-
ability. Both pain self-ecacy (t = 4.74, p < .001)
and pain intensity (t = 2.17, p = .03) contributed to this
relationship. Attachment variables were not correlated
with these dependent variables, suggesting that attach-
ment does not contribute directly to predictions of dis-
ability and pain intensity.
4.7. Testing moderation in the prediction of pain disability
and intensity
In order to explore Hypothesis 3 (that attachment
moderates the eects of pain self-ecacy and anxiety
on disability and pain intensity), a series of regression
analyses (incorporating interaction terms) were conduct-
ed based on the pattern of intercorrelations. Age and
pain duration were included as covariates, and gender
as a xed factor. Pain intensity was also entered as a
covariate in predictions of disability.
Attachment comfort was entered as moderator in
four analyses, with pain self-ecacy and anxiety as
respective independent variables, and disability and pain
intensity as respective dependent variables. Findings
revealed that comfort with closeness moderated the
associations between disability and pain self-ecacy
(F (1, 101) = 5.8, p = .02), and between pain intensity
and pain self-ecacy (F (1, 122) = 7.1, p = .01). All
covariates produced non-signicant main eects and
are not reported. Comfort with closeness also moderat-
ed the association between disability and anxiety
(F (1, 101) = 4.7, p = .03). Again, main eects for covar-
iates were not signicant. These variables were stan-
dardized and, using ModGraph (Jose, 2004),
continuous moderator graphs were developed using
standardized variables. Because the graph using pain
self-ecacy as the independent variable was similar to
that with anxiety as the independent variable, only the
latter is included (see Figs. 1 and 2).
By way of summary, the association between disabil-
ity and pain self-ecacy (B = 1.71, t = 3.66,
 P. Meredith et al. / Pain 123 (2006) 146154 151

Fig. 1. Comfort with closeness moderates the association between pain self-ecacy and pain intensity.

p < .001) was moderated by comfort with closeness ticularly high levels of disability. A similar pattern
(B = .025, t = 2.41, p = .02) such that the combination emerged for the association between perceptions of pain
of low pain self-ecacy and low comfort resulted in par- intensity and pain self-ecacy (B = .189, t = 3.77,

Fig. 2. Comfort with closeness moderates the association between anxiety and disability.
152 P. Meredith et al. / Pain 123 (2006) 146154
p < .001) which was moderated by comfort with close-
ness (B = .003, t = 2.66, p = .01). Low levels of both
comfort with closeness and pain self-ecacy resulted
in particularly high levels of pain intensity. The relation-
ship between disability and anxiety (B = 1.56, t = 3.11,
p = .002) was also moderated by comfort with closeness
(B = .026, t = 2.17, p = .03) such that low levels of
comfort with closeness together with high anxiety were
associated with particularly high levels of disability.
Although these signicant ndings were relatively small,
and should therefore be interpreted with caution, the
identication of similar eects across several outcomes
counterbalances the increase in Type I error rates and
strengthens conclusions. Comfort with closeness did
not moderate the association between pain intensity
and anxiety.
In addition, six similar regression analyses were per-
formed with fearful attachment, preoccupied attach-
ment, and anxiety over relationships as respective
moderators; anxiety formed the independent variable,
and pain intensity and disability, respectively, were the
dependent variables. None of these analyses reached
signicance.
5. Discussion
This project provides evidence of substantial associa-
tions between pain self-ecacy, anxiety, and adult
attachment variables, with implications for perceptions
of pain intensity and disability. Hypothesis 1, addressing
associations between pain self-ecacy, anxiety, and
adult attachment variables, was partially conrmed.
First, anxiety was associated with lower levels of pain
self-ecacy, secure attachment, and comfort with close-
ness, and with more anxious attachment (fearful, preoc-
cupied, and relationship anxiety). In addition, although
not predicted, the dismissing-avoidant attachment cate-
gory was associated with signicantly higher levels of
anxiety relative to the secure group. As anticipated for
pain self-ecacy, the two attachment styles indicative
of attachment anxiety and negative working models of
self (fearful and preoccupied) were linked with lower
pain self-ecacy. Surprisingly, although these anxious
attachment categories demonstrated links with low
self-ecacy, the continuous attachment anxiety measures
did not. Instead, avoidant attachment (low comfort) was
signicantly related to lower pain self-ecacy. This nd-
ing is consistent with research in career decision-making
self-ecacy (Wolfe and Betz, 2004), however contrasts
with theoretical expectations. Overall, ndings oer sup-
port for the association of both anxiety and pain self-ef-
cacy with insecure attachment, highlighting the
vulnerability of those with insecure patterns of attach-
ment in the context of chronic pain.
The second hypothesis of this study was also con-
rmed, with clear associations between pain self-ecacy
and anxiety, and both disability and pain intensity.
Analysis revealed that anxiety and pain self-ecacy
together described 22% of the variance in pain intensity,
while pain self-ecacy was the unique predictor of dis-
ability, accounting for 30% of the variance. Including
pain intensity together with pain self-ecacy predicted
only a further 0.9% of the variance. These ndings are
consistent with the literature portraying pain self-eca-
cy as a primary indicator of disability in chronic pain
(Arnstein, 2000). Interestingly, attachment variables
were not associated with disability and pain intensity.
This nding extends the limited literature available in
the chronic pain eld. Although attachment style has
been associated with disability in patients with episodic
migraine (Rossi et al., 2005), it was unrelated to disabil-
ity for those with chronic migraine (Rossi et al., 2005)
and was unrelated to pain intensity or disability for
those with more dierentiated chronic pain (Ciechanow-
ski et al., 2003).
The nal hypothesis addressed the capacity of attach-
ment variables to moderate the impact of pain self-e-
cacy and anxiety on disability and pain intensity.
Comfort with closeness emerged as the major moderator
variable. Low comfort with closeness (avoidance), when
combined with either high levels of anxiety or low levels
of pain self-ecacy, was associated with higher reported
levels of disability. Similarly, low comfort with closeness
and low pain self-ecacy together suggested particularly
high levels of pain intensity. Considering the highly sig-
nicant association between pain self-ecacy and dis-
ability in this study, these ndings highlight the
protective nature of high comfort with closeness in the
face of chronic pain.
As in other attachment research, gender played a role
in these ndings. Fearful attachment and comfort with
closeness were more strongly associated with pain self-
ecacy for males than for females. In considering this
result, it must be noted that there were a disproportion-
ate number of insecure (low secure, low comfort, and
preoccupied) males in the group, which may have biased
the ndings. This imbalance itself is open to interpreta-
tion. While it may represent sampling bias, it might also
suggest that more men with insecure attachment pat-
terns nd their way to pain treatment facilities, that
male security is more jeopardized by pain, or that inse-
cure men nd it more acceptable to receive assistance in
the guise of treatment for pain.
Results of this study must be regarded as tentative. The
sample was self-selecting and it was not possible to com-
pare ndings of those who agreed to participate with
those who did not. In addition, participants were drawn
only from multidisciplinary chronic pain clinics, further
restricting generalizability (Turk and Rudy, 1990).
Although numbers were initially large, missing data and
the use of the Oswestry disability measure by only those
with low back pain resulted in loss of power for some
 P. Meredith et al. / Pain 123 (2006) 146154
analyses. Given this situation it is perhaps reassuring that
so many signicant associations were obtained.
The use of both categorical and continuous measures
of adult attachment in this study permits consideration
of two dierent conceptualizations of adult attachment.
Since few dierences in the pattern of results between the
two measures emerged, the validity of these ndings is
supported. Interestingly, dierences between the mea-
sures largely involved avoidant attachment. Specically,
dismissing attachment (an avoidant category) was asso-
ciated with high pain self-ecacy, while low comfort
with closeness (an avoidant dimension) was associated
with low pain self-ecacy. Clearly, this issue requires
further empirical attention.
Finally, the cross-sectional design of the present
study prevents consideration of cause and eect, allow-
ing the possibility that the unrelenting experience of
chronic pain may cause a shift towards attachment inse-
curity. This issue of temporal precedence has recently
received empirical attention in a study of pain-free indi-
viduals exposed to a coldpressor task (Meredith et al.,
2006). In this study, pre-task attachment anxiety was
positively associated with pre-task anxiety, and predict-
ed lower pain thresholds and more pre- and post-task
pain catastrophizing.
Although conceptual similarities between adult
attachment theory and other personality variables may
be apparent, comparisons between adult attachment
variables and the big ve personality traits reveal that
these are not redundant constructs (Shaver and Bren-
nan, 1992). For example, Shaver and Brennan (1992)
demonstrated that the relationship between neuroticism
and attachment anxiety is only modest, and Davis and
Vernon (2002) noted that, unlike neuroticism, attach-
ment anxiety is concerned with obtaining and maintain-
ing the approval of others. Acknowledging the
dierences between attachment and personality is partic-
ularly important since personality dispositions underly-
ing chronic pain conditions have been viewed as
refractory to treatment (Geisser, 2004), while adult
attachment security is seen as amenable to therapeutic
intervention. Nevertheless, future research will benet
from comparing the relative contributions of attachment
and personality variables within the same pain sample.
The nding that those in chronic pain with insecure
(avoidant or anxious) attachment patterns are more
aected by anxiety and self-ecacy issues has important
clinical implications. First, it highlights the vulnerability
of this subgroup of individuals and, secondly, it sup-
ports the value of considering attachment-informed
treatment approaches for these individuals. For exam-
ple, it may be a valuable adjunct to the present cogni-
tive-behavioral approaches for those in pain to
consider strategies such as provision of a secure base
of support, use of secure-base priming techniques
(Mikulincer and Arad, 1999; Mikulincer and Shaver,
153
2001), and relationship-based or emotion-focussed psy-
chotherapy approaches (Goodwin, 2003; Sonkin and
Dutton, 2003; Dallos, 2004). In addition, attachment-
style-specic individual dierences in cognitions,
emotions, and behaviors suggest clear directions for
individually tailoring treatment. Stroebe et al. (2006)
have proposed attachment-informed modications to
the therapeutic disclosure paradigm, suggesting that at-
tachment-style-specic disclosure instructions (Stroebe
et al., 2006, p. 66) are likely to improve the therapeutic
benet of this intervention.
6. Conclusion
Results of this study oer the rst evidence that
attachment theory is meaningfully related to pain self-
ecacy and anxiety in the context of chronic pain, and
that it moderates the impact of these variables on dis-
ability and pain intensity. In particular, ndings high-
light the vulnerability of those low in comfort with
closeness (avoidant) and high in relationship anxiety.
These ndings clearly warrant further empirical and
clinical attention.
Acknowledgements
The authors thank the sta and clients of both Pain-
Logic and Gregory Terrace Rehabilitation. The sugges-
tions of two anonymous reviewers, the statistical advice
of Dr. Ross Darnell, and the input of Dr. Tamara
Ownsworth have also been appreciated. This research
was supported by a joint scholarship from the Graduate
School Postgraduate Research Studies Unit and the
School of Health and Rehabilitation Sciences at The
University of Queensland, Australia.
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