Last October, I spoke at the Ancestral Health Society of NZ bi-annual Symposium. An inspiring audience came together in Queenstown - some patients, some health providers, all interested in ancestral health. The topic was how the relationship we have with others, including our health providers, can affect our health outcomes for better or for worse. Here’s how.
Supportive relationships protect health, but some relationships have a more powerful effect on health than others. These are called our attachment relationships and we experience the first of these in our parents/caregivers, then our close peers, romantic partners, and significant mentors or health professionals. Survival favours caregivers being close by to care for their children until they become independent. Our species (and other mammals) needed a system that ensured the first few years of life went according to plan – a reliable way of staying close to the caregivers who keep you safe and alive. Enter the attachment system.
Attachment serves the evolutionary goal of helping offspring survive, and enables individuals of any age who feel threatened to re-establish physical and emotional security through contact and comfort. I have written about adult attachment styles in a previous blog here which describes secure attachment and the three insecure attachment templates – preoccupied (amplification), dismissing (minimisation), and disorganised (fluctuation). Our default template occurs through our repeated relationship experiences which, while is most significant in infancy and childhood, can also be altered by relationships across the lifespan. We naturally develop adaptive strategies to cope with inconsistent, unavailable, or abusive attachment relationships. If you don’t check my attachment style blog out before reading on then the rest might not make much sense! But to summarise the attachment styles in a nutshell, secure attachment is characterised by these nice experiences:
- Feeling worthy of care and love
- Being (generally) trusting of others to care for us
- Gaining mentalising skills (i.e., imagining the mental/emotional perspective of others - related to empathy skills)
- Gaining the ability to self-soothe when in distress or pain
- Forming the ability to delay gratification
In contrast, insecure attachment is characterised by some less easy experiences such as:
- Reduced self-regulation of stress/emotions
- Difficulties seeking effective social support
- Amplifying and/or Minimising techniques (see below)
- Effects on the gut-brain-axis and a less calm autonomic nervous system ("jumpy" vagus nerve, over or under-activated HPA axis, and effects on the gut including dysbiosis/intestinal permeability/impaired absorption)
Preoccupied Attachment (Amplification):
- Relationships have been inconsistent
- Connection has been unreliable/vulnerable
- Protective mechanisms are to amplify behaviour that seeks closeness (e.g, approval/reassurance and to heighten distress)
- May struggle with anxiety and distress and with calming down
- Heightened protest at separation from loved ones
- May seek health provider support at increased rates
Dismissing Attachment (Minimisation):
- Relationships have been unavailable/rejecting
- Connection has been unavailable/disconnected
- Protective mechanisms are to become independent (i.e.., "I don't need others")
- Tend to deny closeness needs, avoids relationships (to avoid rejection/hurt), under-report symptoms/distress
- May seek out external forms of avoiding feelings/self-soothing (sex, alcohol, gambling, work)
- Avoid health care provider when unwell - compulsive independence
Do you see yourself in any of these styles? There is a further insecure pattern that fluctuates between Amplification and Minimisation, which is generally associated with relationships that have been abusive or dangerous but this won't be focused on here.
Whichever way it develops, your attachment system is a complex “meta-system.” This implicates multiple physiological systems, hormones, and neurotransmitters when it is activated ranging from oxytocin and vasopressin (bonding and commitment hormones), adrenalin and cortisol (stress and threat hormones), and those implicated in reward (dopamine and endogenous opiates – endorphins), relaxation (GABA), and contentment (serotonin). Illness, pain, separation, loss, and distress all activate this meta-system, and trigger default attachment behaviour (whichever template you developed).
In the literature, insecure attachment is associated with diabetes, cardiovascular issues, inflammatory diseases, ‘medically unexplained symptoms’, psychological concerns, and can drive chronic stress. Chronic stress is associated with raised inflammatory cytokines (Interleukin IL-1 and IL-6, and tumour necrosis factor,) and less anti-inflammatory cytokines that terminate the inflammatory response. This relates to the cytokine theory of mental health concerns, whereby a combination of chronic psychological, dietary, lifestyle, and interpersonal stressors contribute to an inflammatory response and mental health symptoms like anxiety or depression.
Long term exposure to stress can also result in desensitised glucocorticoid receptors to cortisol (cortisol resistance), chronic low-grade inflammation with a reduced immune response, and changes to brain-derived neurotrophic factor (BDNF; which aids brain growth and plasticity, insulin sensitivity, and parasympathetic/relaxation system tone). Long-term exposure to stress can also churn through vital nutrients needed for optimal functioning, and can adversely impact on the gut lining via impaired digestion/stomach acid, contributing to gut permeability. This places the individual at risk of nutritional deficiencies that further worsen the original insults and cause more symptoms, as the physical foundations are compromised. In addition, when chronically stressed we are more likely to use health detracting behaviour to numb, avoid, or change how we feel, such as alcohol/smoking/caffeine, poor nutritional choices, avoiding meaningful social connection, and to reduce our health helping behaviours like getting quality sleep, nutritious food, and movement.
There are various interesting studies looking at attachment and immune functioning that I find fascinating. Chronic social stress has been found to impair vaccine responses, delay wound healing speed, and dysregulate cellular immunity. EBV virus (glandular fever) latency has been found to be higher in those with preoccupied attachment (but not dismissing). Those with preoccupied attachment had delayed or impaired recovery from glandular fever compared to those with other attachment styles. Gut microbiota disruption during critical developmental windows has also been found to occur, with effects on the modulation of the immune system and changes in hormones and neurotrophins (proteins that determine neuronal outcomes). There are also epigenetic changes found. For example, some genes seem to be “socially sensitive” and may switch on or off depending on attachment experiences. Those with preoccupied attachment experience significantly greater number of physical symptoms compared to other patients (Liechanowski, 2002). This makes sense, right? With preoccupied attachment the HPA axis is jumpy (feel more stressed/anxious), vagal tone is poor (it's harder to calm down), and the gut is impacted by chronic relational stress and all the things going on above. Over time immune functioning can be impaired causing further health issues, especially chronic types such as autoimmunity.
Those with chronic health issues or chronic symptoms with a lack of diagnosis, or hard to understand conditions, often get classed as “psychosomatic” by nature (E.g., chronic fatigue syndrome, fibromyalgia, chronic pelvic pain, IBS, non-cardiac chest pain, tension headache, multiple chemical sensitivities, autoimmune conditions, chronic anxiety/depression, and cases entitled ‘forme fruste’ - below threshold for diagnosis).The label "psychosomatic" inappropriately emphasizes psychological factors and attributions in the cause of these difficulties (i.e., "It's all in your head"). People experiencing such health symptoms have usually had repeated invalidation by health professionals who haven't found a cause (and others in their life who struggle to understand their experience), and this can cause epistemic distrust that the medical profession or others will not adequately believe or care about them.
These people are not ‘difficult to treat’ but can be difficult to reach because of this repeated invalidation (whether intentional or not) when help seeking. As well as this, they often experience trauma from their body with symptoms that seem often frightening and out of their control. This kind of diagnosis also reinforces insecure attachment. In my opinion and experience, these individuals are the most in need integrative approaches of physical health/nutrition/gut health and attachment and stress work.
The Good News
When illness or injury activates the attachment system through distress and vulnerability, relationally appropriate responses by health professionals can be healing, with the following benefits seen:
- Responsive attuned care = corrective attachment experience
- Offsets the stress response - can reduce cortisol
- Promotes healing – can reduce inflammation
- Reduction in anxiety and distress
- Maximises treatment adherence
- Is correlated with patient satisfaction
- Improves health outcomes
Health care providers have a powerful intervention available to them at any moment in their relational responsiveness to their clients/patients. We've probably all had an experience of going along to talk to someone about our health concern and having not felt heard, understood, believed, or cared about. Yet, one study found that the duration of the common cold was reduced by one full day, simply by the doctor making a caring statement! If this was a new medication it would be all over the news.
In practice, relational responsiveness includes building rapport - being predictable, attentive, supportive. To be soothing of distress and anxiety through facial expressions, voice tone, and body language. To listen compassionately, believe the experience, and to focus on distress rather than content (initially). Consider the full spectrum of gut-brain-axis solutions that can help from body-work practitioners, Yoga/mindfulness/relaxation, nutrition, talk therapy alongside traditional medical interventions.
Dualistic models in health just don’t work. We are not just a mind or a body, or even a mind-body, we are a mind-body-other. We’re not a gut or a brain, or a gut-brain, but a gut-brain-other. As we focus more and more on nutrition and gut health, lifestyle and stress, and epigenetics let us not forget that these aspects of a human are always in the context of their relationships – especially their attachment relationships - and don't forget that if you are a health provider you may be one of these.
Cassidy, J., & Shaver, P.R. (Eds.). (2016). Handbook of attachment. Theory, research and clinical applications. (3rd Ed). New York: Guilford Press.
Cirulli, F. (2014). Interactions between early life stress and metabolic stress in programming of metal and metabolic health. Current Opinion in Behavioral Sciences, 14, 65-71.
Dean, J. & Keshavan, M. (2017). The neurobiology of depression: An integrated view. Asian Journal of Psychiatry, 27, 101-111.
Fagundes, C.P., et al. (2014). Attachment anxiety is related to Epstein-Barr virus latency. Brain, Behavior, and Immunity, 41, 232-238.
Greenblatt, J. M., & Brogan, K. (Eds.). (2016). Integrative Therapies for Depression: Redefining Models for Assessment, Treatment and Prevention. CRC Press.
Hunter, J., & Maunder, R. (Eds.). (2016). Improving patient treatment with attachment theory. A guide for primary care practitioners and specialists. Springer Publishing.
Maunder, R., & Hunter, J. (2015). Love, fear and health: How our attachments to others shape health and healthcare. University of Toronto Press.
McEwen, B. S., & Lasley, E. N. (2002). The end of stress as we know it. Joseph Henry Press.