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    2020-08-18

    Contents lists available at ScienceDirect
    Journal of Psychosomatic Research
    journal homepage: www.elsevier.com/locate/jpsychores
    Attachment security and existential distress among patients with advanced T cancer
    a Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
    b Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
    c Department of Medical Psychology and Sociology, University Medical Center Leipzig, Leipzig, Germany
    d Department of Medicine, University of Toronto, Toronto, Ontario, Canada
    e Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
    f Social and Behavioural Health Sciences, Dalla Lana School of Public Health, University of Toronto, Canada
    Keywords:
    Demoralization
    Attachment security
    Psychological adaptation
    Existential distress
    Advanced cancer
    Palliative care 
    Background: Felt security in close relationships may affect individual PX 478 responses to existential threat in severe illness. We examined the contribution of attachment security to demoralization, a state of existential distress involving perceived pointlessness and meaninglessness in advanced cancer.
    Method: A mixed cross-sectional sample of 382 patients with advanced cancer (mean age 59, 60% female) was recruited from outpatient oncology clinics. Participants completed self-report measures of attachment security, demoralization, depression, and physical symptom burden. We used multiple linear regression to analyze the association between attachment security and demoralization, controlling for demographic factors and symptom burden and tested whether attachment security moderated the association of symptom burden with demor-alization. Separate analyses compared the contribution of the dimensions of attachment anxiety and attachment avoidance.
    Results: The prevalence of clinically relevant demoralization was 35%. Demoralization was associated with lower attachment security (β = −0.54, 95%CI: −0.62 to 0.46). This effect was empirically stronger for at- tachment anxiety (β = 0.52, 95%CI: 0.44 to 0.60) compared to attachment avoidance (β = 0.36, 95%CI: 0.27 to 0.45). Attachment security also significantly moderated the association of physical symptom burden with de-moralization, such that with less attachment security, there was a stronger association between symptom burden and demoralization.
    Conclusion: Attachment security may protect from demoralization in advanced cancer. Its relative lack, parti-cularly on the dimension of attachment anxiety, may limit adaptive capacities to deal with illness burden and to sustain morale and purpose in life. An understanding of individual differences in attachment needs can inform existential interventions for severely ill individuals.
    1. Introduction
    Individuals with advanced cancer face unique existential challenges that can cause substantial distress. Disease progression and the threat of mortality may confront them with a loss of the sense of continuity, autonomy, and meaningful activity and may trigger anticipatory fears about the future [1,2]. Such existential losses and fears may activate attachment needs for security and intimacy and disrupt the equilibrium in existing close relationships [3–5]. Attachment styles may influence
    psychological adaptation in this context, and those with less attachment security or less flexibility in their attachment relationships may be at heightened risk to develop existential distress. The latter refers to ex-periencing life as pointless, without hope or meaning, or feeling worthless and a burden to others [6].
    Adult attachment styles may affect individual adaptation responses to existential threats and insecurities in the context of medical illness [7]. According to attachment theory, securely attached individuals have internalized the availability of helpful others because of their early
    Corresponding author at: c/o Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, 16-724, Toronto, Ontario, M5G 2M9, Canada. E-mail address: [email protected] (S. Vehling).
    S. Vehling et al.
    childhood experiences. They tend to experience themselves as deser-ving of support and may be more able to obtain instrumental and emotional help in stressful situations. Those with less attachment se-curity may have greater difficulty making use of relationships: more anxiously attached individuals tend to worry that help will not be available and to have less confidence in their own self-regulatory abilities; more avoidantly attached individuals may tend to minimize distress and to become compulsively self-reliant. The former tend to have hyperactivating responses to threat, with fears of abandonment and feelings of helplessness, while the latter tend to deactivate in this circumstance, seeking emotional and physical distance from others to reduce dependency [5].