A fearful adult attachment style is associated with double the prevalence of chronic pain compared to secure attachment: A national survey of a South African population

Our response to threats, including pain, are believed to be learnt during our early interpersonal relationships, and can be measured through attachment style. Preliminary epidemiological evidence suggests that insecure attachment styles are more prevalent in those with chronic pain. Our aim was to determine the association between adult attachment style and chronic pain prevalence and burden in a South African population. A nationwide online survey determined adult attachment style (using The Experience in Close Relationships - Relationship Structures (ECR-RS) Questionnaire), prevalence of chronic pain and typically-associated psychological factors. In those with chronic pain, the association with attachment style and pain burden (pain sites, severity and interference, using the Brief Pain Inventory) was further determined. Results of the 2371 individuals were analyzed using multivariate generalized linear models. In our young (median age 23 years; IQR 20-28), well-educated and primarily female (74%) cohort with predominantly a middle-to-high socioeconomic status, we found a high prevalence of chronic pain (27%). All three insecure attachment styles were associated with increased chronic pain prevalence when compared to the secure attachment style (Dismissing: 31%, Odds ratio [95%CI] = 1.38 [1.02-1.85], p=0.037; Preoccupied: 42%, Odds ratio [95%CI] = 2.26 [1.62-3.13], p<0.001; Fearful: 49%, Odds ratio [95%CI] = 2.95 [2.03-4.29], p<0.001). Adult attachment style was not directly associated with the burden of chronic pain, because pain catastrophizing mediated this relationship. Adult attachment style was, however, directly associated with chronic pain prevalence, with more than double the chronic pain prevalence in the fearfully, compared to securely, attached individuals.