Review of attachment interventions in eating disorders: Implications for psychotherapy

Abstract

Background Attachment theory has been used in personalized treatments since decades. It is a major framework for understanding images of the self, affect regulation, reflective functions and interpersonal relationships. The improvement of attachment functioning is associated with positive treatment outcomes in eating disorders. However, attachment interventions have not been summarized in their psychotherapy. Aims The aim was to review the relevance of attachment features in the psychotherapy of eating disorders. Methods A literature review was carried out for empirical review and case studies, using the terms “eating disorder” and “attachment” from 1987 until 2017. From the 320 matches, 50 relevant studies were integrated into this review. Results The relationship between dysfunctional attachment and eating disorders could be conceptualized in seven ways, including transgenerational transmissions and mediator personality traits. Attachment can mediate between early experiences and adult symptoms, between intra- and interpersonal experiences, or may moderate the relationship between the risk factors and maladaptive eating. Attachment features also display a direct relationship with eating disorders, or may underlie their maintaining mechanisms. Nine psychotherapeutically relevant mediator factors could be identified, namely the patient’s self-concept and emotion-regulation, the conflation of self-esteem and body satisfaction, a sensitive interpersonal style, levels of perfectionism, depression, alexithymia, mentalization and reflective functions. Conclusions The assessment of attachment dysfunctions in the individual symptomatology may facilitate personalized case models. For patients with severe attachment dysfunctions, multimodal psychotherapies targeting the described focal points could be recommended. Randomized, controlled studies are required to test the efficacy of the interventions summarized, and to determine indications.