The vulnerability to interpersonal stress in eating disorders: The role of insecure attachment in the emotional and cortisol responses to the trier social stress test

Background: Vulnerability to interpersonal stress is an important risk factor for Eating Disorders (EDs). Adult insecure attachment involves different emotional, biological and behavioural strategies to cope with social stressors. However, although attachment has proved to play a pivotal role in EDs, no study has yet explored the effects of attachment on the emotional and hypothalamic-pituitary-adrenal (HPA) axis responses to a psychosocial stressor in EDs. Methods: Fifty-two ED women (29 with anorexia nervosa, 23 with bulimia nervosa) underwent the Trier Social Stress Test (TSST). Their emotional response was measured by means of the State-Trait Anxiety Inventory state scale while saliva samples were collected to measure cortisol secretion. Results: According to the Experience in Close Relationship questionnaire scores, 21 ED patients had high attachment anxiety and 31 low attachment anxiety, whilst 34 had high attachment avoidance and 18 low attachment avoidance. Patients with high attachment anxiety or avoidance displayed heightened TSST-induced cortisol secretion and anxiety feelings, in comparison to those with low insecure attachment scores. Anxiety perception was associated with cortisol recovery after the test exposure but not with the HPA axis reactivity in insecure attached patients. Conclusions: The present findings corroborate the hypothesis that attachment modulates the biological and emotional reactivities to an acute social threat in ED patients. The role of these attachment-mediated changes in vulnerability to interpersonal stress in EDs needs to be clarified in future studies.