Eating Disorders Treatment Through an Attachment Lens

Eating disorders (EDs) are complex conditions stemming from a vast range of causes, and recent studies have suggested a causal relationship between disordered eating and attachment insecurity. A meta-analysis conducted in 2023 and published by the International Journal of Eating Disorders supported the hypothesis of a connection between anxious and avoidant attachment patterns in early life and the development of eating disorders.

So, what do we mean when we talk about Attachment Styles? John Bowlby, a psychiatrist and psychoanalist and the founder of Attachment Theory, defined attachment as the emotional connection and bond between a child and a caregiver. These patterns inform and shape the child's "working models" of the world, a.k.a. the core ideas about the whe world and relationships that subconsciously inform how we relate to others. Bowlby identified four different attachment styles:

1. Secure Attachment: Developed through present, intentional and consistent caregiving, it fosters a sense trust and safety in relationships. Children who develop a healthy attachment are more likely to replicate this healthy bond in their adult relationships.

2. Anxious Attachment: It often results from inconsistent caregiving and discipline throuought childhood. It can also develop in adulthood as the result of unhealthy and abusive relationships. It creates a strong fear of rejection and abandonment.

3. Avoidant Attachment: It develops in childhood in response to a dismissive, neglectful parent. It creates the perception that a child's thoughts and feelings are not important. Adults with avoidant attachment often struggle with intimacy in relationships and are often accused of being emotionally unavailable in romantic relationships.

4. Disorganized Attachment: It is the attachment style linked to abusive, frightening and otherwise unavailable parents. Research suggests there is a strong connection between disorganized attachment and a later onset of symptoms related to anxiety disorders and other behavioral problems.

Anxious vs. Avoidant Attachment in Eating Disorders

People with anxious attachment suffer from a deep fear of abandonment and rejection; they often seek external validation and experience high levels of anxiety within a relationship. Many patients suffering with disordered eating often often seek validation and experience deep fear of rejection. They develop eating disorders as a way to cope with low self-esteem, poor self-concept and feelings of rejection. Conversely, individuals with avoidant attachment are more likely to shut down emotionally, to dismiss or invalidate as a coping strategy for their fear of being vulnerable. Avoidantly attached individuals may use food to exert control and escape intimacy and connection.

Integrating Attachment Theory in Treatment

Eating Disorders are very complex psychological and physiological conditions requiring a sophisticated, multi-disciplinary approach. While treatment paradigms such Dialectical Behavioral Therapy (DBT) and Cognitive Behavioral Therapy (CBT) have produced significant positive treatment outcomes, there is always potential to expand the scope of research and treatment to reach new horizons. Recent studies focused on somatic modalities such as Polyvagal Theory have been very promising.

If we consider the importance and benefits of trauma-informed care, we cannot deny the significance of addressing the client's attachment history and related traumas in a comprehensive, holistic treatment plan. Treating eating disorders through an attachment lens can offer significant benefits.

Therapists willing to explore attachment histories open a window of opportunities to repair old ruptures in trust and intimacy, which is a crucial step in recovery.

Clients who are open to understand their attachment histories gradually learn about their emotional threshold and needs, reducing their dependence on disordered eating to cope with difficult emotions.

Clinicians have here the opportunity to deepen the healing process by encouraging safe exploration and building trust, vs. strictly directing the client towards behavior modification.

It's safe to assume that the integration of attachment work has the potential to improve treatment outcome and long lasting results, as it targets the relational, behavioral and relational aspects of disordered eating.