Attachment Style and the Predisposition to Eating Disorders in Adolescence

This study arouses from my personal interest to understand more about the attachment styles processes of the teenage girls and the predisposition to develop an eating disorder. Eating disorders in adolescence are being widely noted in the albanian society. Individuals affected more often by eating disorders are women, mostly girls in late adolescence and early adulthood age. The purpose of this study was to focus on exploring the relationship between the tendency to develop an eating disorder and attachment style of teenage girls 15-18 years old. In this study participated 287 teenage girls. They completed two measure instruments: Multidimensional eating disorder Inventory-Garner, Olmstead & Polivy (1983) which measured respectively eating disorders symptoms and Batholomew’s Attachment Style Inventory (1991) which measured the attachment styles of the teenage girls. The hypothesis of the current study was that there was a significant link between unhealthy attachment styles (unsecure, avoidant, disorganized) and the tendecy to develop an eating disorder at teenage girls 15-18 years old. The result in the end of th study was that there is a statistically important relationship between the tendency to develop an eating disorder and unhealthy attachment styles (unsecure, avoidant, disorganized). The study showed that the correlation between unhealthy attachment styles and tendency to develop an eating disorder was significant. Teenage girls with unhealthy attachment styles showed more symptoms of eating disorders, they were in border to develop an eating disorders or they already had one.

There is a basic approach in clinical psychology, by which the quality of close and emotional relationships we create with other people, have a significant impact on mental health problems.The theory of attachment, originating from the work of John Bowlby (1988), has been in the attention of many researches of the clinical psychology field and reseachers who want to understand more about eating disorders and their relation to attachment styles.
There are a several reasons why is increased the interest to researchers who want to understand more about the pathologies of mental health.First, the attachment theory today integrate empirical testable constructs and scientific reliable measurement and accurate.Second, based on several studies, it is proved from available empirical data available that exist a connection between the quality of attachment and mental health problems.Many researcher believe even that attachment stye is a primary and dominant factor in the emergence of mental health problems (Dozier, Stovall-Mcclough, & Albus, 2008).Third, attachment theory integrates ideas from different therapeutic approaches such as psychoanalysis (Fónagy et al., 1996), cognitive therapy (Liotti & Pasquini, 2000) and family therapy (Kozloёska & Hanney, 2002).
Finally, this multidisciplinary theoretical background provides a means to understand the interaction of individual and family characteristics (Hill, Fónagy, Safier, & Sargent, 2003) and these are particularly important in the clinical work of psychologists with girls with anorexia and bulimia.In the past two decades there is a considerable number of published studies exploring the relationship of attachment styles and eating disorders.

2.Attachment and eating disorders
Attachment is a strong and stable emotional connection between mother (or primary care) and child in the first years of life.Attachment is at the roots of the controlling models of motivational sistem (Bowlby, 1988).It was John Bowlby (1988), who considered this relationship mother -child of a special importance, monitoring in his clinical practice problems of this relationship.Generated by his theory, attachment theory, is rooted in Freud's psychoanalytical treatises and object relations theory.Attachment theory focused on the crucial importance that this relationship has on the subsequent development of the individual mental health.
Although Bowlby (1988) had focused his work as a psychologist primarily in parent-child relationship, he believed that attachment is a process that begins where we born and continues until we die.Only in the mid-80s the researchers began to see seriously the fact of how early attachment figures, werw a determinant factor of how an individual creates adult relationships through internal models of operation.Hazan and Shaver (1987) were the first two researchers who explored the ideas of Bowlby in the narrow context of romantic relationships or between peers created in adolescence and adulthood.Hazan and Shaver (1987) felt that romantic relationships in adulthood as caretaker-child relationship is an attachment relationship, and that romantic love is part of behavioral attachment system that has bases in our childhood.
The relationships that we have established with our parents or primary caregivers, expectations, feelings and beliefs that we have had in this relationship will be generalized in all attachment relationships that we will create in adulthood, including close emotional relationships, with romantic partners, peers, etc.According to the authors, on the basis of mental schemes created by the early relationship we create all of our relationships in life as adults, and those mental schemes are completely unaware (Hazan & Shaver, 1987).If the relationship with the primary caregiver was safe, then the individual is likely to create secure relationships with others and relationships based on trust.
In recent years, many studies had been based on Bowlby's theory of attachment (1988).Initially, the theory aimed to explain the psychopathologies of children and adults in the context of early problematic relationship between the child and the primary caregiver.According to the theory of attachment,the long-term effects of ealry experiences with "attachment figure" are effects saved in our memory through the creation of the "internal working models" -cognitive / emotional schemes, or representations of ourselves in relation to partners or individuals which we create close emotional relationships (Bartholomew, 1990).
Theoretically, these representations affect our expectations to others, emotions, defenses, and relational behavior in all close relationships.Although the theory does not require to assume that this internal working models are totally unchangeable, anyway this internal working models continue to be fairly constant during the whole life.As the theory as well as empirical evidence from longitudinal study led researchers into believing that the effects of attachment relations during childhood extend into adulthood, and these effects can be seen in the relationship with parents and close relations between colleagues, including romantic relationships (Bartholomew, 1990).
Extensive researches associate early attachment with eating disorders based on parent-child relationship.The findings are generally complicated, but are stable.First, girls who have anorexia described their parents in a negative way (Vidovic, Jurassic, Begovac, Mahnik, & Tocijlk, 2005).Second, fathers are mainly described as emotionally distant and dismissive (Cole-detka & Kobak, 1996).Third, mothers are described as dominant, overprotective and perfectionist (Minuchin, Rosman, & Baker, 1980;Woodside et al., 2002).Finally, parents seem to behave in a manner detrimental to the development of independence and autonomy (Ratti et al., 1996).
Various studies have seen the connection between AAI (Adult Attachment Interview) and eating disorders Cole-Detka and Kobak (1996) self-reporting scale was also used for the evaluation of the attachment style and eating disorder.From this study came out that teenage girls with eating disorder were categorized more with avoidant attachment.Girls who had symptoms of eating disorders and also showed depression were classified with disorganized attachment style.In contrast to this study, Fonagy and his colleagues (1996) found that 64% of girls with eating disorders wew classified with disorganized attachment, but girls who also had comorbid depression were classified with avoidant attachment style.

3.Aim of the study and hypothesis
This study arouse from my personal interest to understand more about the attachment styles processes of the teenage girls and the predisposition to develop an eating disorder.Also this study originated as a result of lack of studies regarding this topic in Albania.This the first study which aims to understand more about the connection between the predisposition to develop an eating disorder and attachments styles of 15-18 years old teenage girls in Albania.
The aim of this research was to explore the relationship between the attachment styles of 15-18 years old teenage girls and their predisposition to develop an eating disorder.The hypothesis of this study was : Teenage girls 15-18 years old which show an unhealthy ttachment style (unsecured, avoidant, disorganized), will also show the predisposition to develop an eating disorder.Objectives of the study are : 1.To identify attachment styles of 15-18 years old teenage girls.2. To identify the teenage girls which show symptoms and predisposition to develop an eating disorder.3. To find the correlational link between the tendency of developing eating disorders and attachment styles of the teenage girls.4. To offer recommendations for professionals during their labor with adolescent girls regarding an understanding of attachment style processes and tendency to develop eating disorders.

4.Methodology
The study sample consists of 300 adolescent girls aged 15 to 18 years living in Tirana.Were chosen only girls according to the aim of the study and also because approximately 90% -95% of patients with eating disorders are girls between 15-18 years old (Steiner & Lock, 1998).In the current study 7% of the sample were 15 years old girls; 32.3% of participants were 16 years old; The majority of girls were 17 years old or 45.7% of the sample, and 18 years old girls constitute 15% of the sample.Answers of 13 girls resulted not valid, and the results of the study were extracted from the final sample of 287 teenage girls.Individuals who participated in this study may exhibit symptoms of eating disorders or not.The sample selection of this study was based on a randomized selection as the appropriate tool for the study realized.School names were written in white letters and from all schools were randomly selected 5 high schools.The hight schools selected to realize this study were : Sami Frashëri, Partizani, Sinan Tafaj, Andon Zako Ҫajupi and Ismail Qemali.

Measure instruments
To carry out my study I have used three instruments measuring : Attachment Style Inventory (Bartholomew,1991) and that should be diagnosed for determining the specific type of disorder that may be anorexia, bulimia, etc.It is constructed according to the Likert-Scale from 1(never)-5(always).Time management is 20 minutes.
Questionnaire of Demographic Data : The instrument contains questions about the age, the class that attends, hometown, social and economic status, parents educational level and religious faith of individuals participants in the study.In this study will not be used all the data derived from this questionnaire, but will be used only data available in function of the current study.Other data provided are in function of future studies I can do in this area.

5.Results
The In the Table 2. we see that the greatest proportion of teenage girls vjeҫ 15-18, 67.9% are categorized as "normal" by the Multidimensional eating disorder inventory-Garner, Olmstead & Polivy (1983).So, for the most part of girls participating in the study show no symptoms or risk of developing an eating disorder; 29.6% of them are located on the border and potentially endangered to develop an eating disorder; 2.4% of them already already had an eating disorder and they should be diagnosed to specify the eating disorder and take the right treatment.
Below are presented the categorization of teenage girls attachment styles, according to their responses, given in Attachment Styles Inventory (Bartholomew, 1991).From the Table 3, results that form 287 teenage girls 22% of them had secure attachment style, 31.3% of them had insecure attachment style, 29.9% had disorganized attachment style and only 16.7% of them exhibit avoidant attachment style in relations with others.
In Table 4 are given the responses of the participants in the study according to the eating disorders and attachment styles.From this table we noticed that the girls which did not exhibit eating disorders or predisposition to develop an eating disorders, have these attachment styles in their relationships with others : 32.3% have secure attachment style, 30.3% have insecure attachment, 25.6% the teenage girls which did not exhibit eating disorders or predisposition to develop an eating disorders have disorganized attachment style;11.8% of their have avoidant attachment style in establishing relations with others.
From teenage girls to 15-18 years old, which are on the border with eating disorders and have a predisposition to develop an eating disorder, none of them have secure attachment style in establishing relations with others.34% of them have insecure attachment, 39% have disorganized attachment style and 27% of girls who are on the border with the emergence of eating disorders have avoidant attachment style.

Correlation
Below are presented tables with the correlations values between variables expressed of study.In the table below is shown the correlational relationship between risk or predisposition to develop an eating disorder (on the border with eating disorders) and secure attachment style.The table 5 also shows that there is a strong negative correlation (r = -0.62 '') between secure attachment style and the risk to develop an eating disorder.This means that girls who have secure attachment style aren't risked to develop an eating disorder.In the table 6 we see also that there is a significant positive correlation between insecure attachment and the predisposition to develop an eating disorder (r = 0:28 ").This presupposes that girls which shoq an insecure attachment style are more likely to develop an eating disorder.So, in the emergence of insecure attachment, increases also the possibility / the risk of developing an eating disorder.On the table 7 is shown the correlation between the disorganized attachment style and the risk of developing an eating disorder.The table shows that there is a strong positive correlation between the predisposition to have an eating disorder and disorganized attachment style (r = 0:37 '').This means that the increased likelihood of having a disorganized attachment style in establishing relations with others, increase also the possibility of developing an eating disorder of the teenage girls participants of the study.From the table 8 it is observed that there is a significant positive correlation between avoidant attachment style and predisposition to develop an eating disorder (r = 0:25 '').This correlation means that with the increased likelihood of having avoidant attachment style in establishing relations with others, increases also the risk to have an eating disorder.On the other hand it presupposes that teenage girls, which display a predisposition to have an eating disorder, are more likely also to have avoidant attachment style.

6.Discussion
The study sample consists of 300 adolescent girls aged 15 to 18 years living in Tirana.Were chosen only girl according to the aim of the study and also because approximately 90% -95% of patients with eating disorders are girls between 15-18 years old (Steiner & Lock, 1998).In the current study 7% of the sample were 15 years old girls; 32.3% of participants were 16 years old; The majority of girls were 17 years old or 45.7% of the sample, and 18 years old girls constitute 15% of the sample.Answers of 13 girls resulted not valid, and the results of the study were extracted from the final sample of 287 teenage girls.Individuals who participated in this study may exhibit symptoms of eating disorders or not.
The aim of the study was to explore the relationship between the attachment styles of 15-18 years old teenage girls and their predisposition to develop an eating disorder.The hypothesis of this study was : Teenage girls 15-18 years old which show an unhealthy attachment style (unsecure, avoidant, disorganized), will also show the predisposition to develop an eating disorder.So in this study was hypothesised that there was a significant correlation between unhelathy attachment style and the risk to develop an eating disorder.The hypothesis of this research was confirmed.
The study revealed that the greatest proportion of teenage girls vjeҫ 15-18, 67.9% are categorized as "normal" by the Multidimensional eating disorder inventory-Garner, Olmstead & Polivy (1983).So, for the most part of girls participating in the study show no symptoms or risk of developing an eating disorder; 29.6% of them are located on the border and potentially endangered to develop an eating disorder; 2.4% of them already already had an eating disorder and they should be diagnosed to specify the eating disorder and take the right treatment.Even by the Association American Psychiatric (2000), only 3-5% of the adolescents develop an eating disorder.Without having a strong sense of identity, teenage girls starts to feel bad about their appearance and thei go towards keeping diets and raising expectations unrealistically about their appearance, going on this way towards developing an eating disorder (Rosen, 1993).Adolescence is an important period which need to be studied, because it can be a critical period for the development of eating disorders (Silverstone, 1992) From teenage girls to 15-18 years old, which are on the border with eating disorders and have a predisposition to develop an eating disorder, none of them have secure attachment style in establishing relations with others.34% of them have insecure attachment, 39% have disorganized attachment style and 27% of girls who are on the border with the emergence of eating disorders have avoidant attachment style.Various studies have seen the connection between AAI (Adult Attachment Interview) and eating disorders Cole-Detka and Kobak (1996) self-reporting scale was also used for the evaluation of the attachment style and eating disorder.From this study came out that teenage girls with eating disorder were categorized more with avoidant attachment.Girls who had symptoms of eating disorders and also showed depression were classified with disorganized attachment style.In contrast to this study, Fonagy and his colleagues (1996) found that 64% of girls with eating disorders wew classified with disorganized attachment, but girls who also had comorbid depression were classified with avoidant attachment style.Button (1996) have followed this line of research in different cultures and have found out the close connection between attachment and self-evaluation.Patients with eating disorders exhibit associated low self-esteem, such as problems with self-image and overall their exaggerated fears about weight and body shape, and globally negative attitudes about self-control and discipline.

7.Study Ethics
The entire information gathered from the study was totally anonymous.All the participants in the study were informed about the aim of the study, procedures and confidentiality and all the girls participated voluntary in the current study.It's avoided any physical or psychological damage of the participants.After getting all the nessesary information all the participants firmed the "Consent Form".

8.The contributions of this study
This is the first study in Albania, which shows that there is a relationship between the tendency to develop an eating disorder and attachment styles of 15-18 years old teenage girls.Eating disorders are dedicated usually as a consequence of social ideals and standards about the beauty, consequence of the impact of the media as well.Meanwhile, this study attempted to concept them closely related to unhealthy attachment styles.

9.Researches in the future
I would suggest future researches exploring the relationship of eating disorders and attachment styles in a sample of diagnosed patient with anorexia or bulimia.In Albania are absent such studies and also standardized measurement instruments.Other researches are necessary about intervention programs for teenage girls suffering from an eating disorder.All clinical psychologist working with teenagers, should gain a deep understanding of psychological processes of teenage girls with an eating disorder or with the predisposition to develop an eating disorder.This can lead us to prevention or the right treatment program.

10.Conclusions
The aim of the study was to explore the relationship between the attachment styles of 15-18 years old teenage girls and their predisposition to develop an eating disorder.From the study resulted that there is a strong positive correlation between unhealthy attachment styles and eating disorders.On the other hand girls with secure attachment style did not show the presence of an eating disorder or a predisposition.Also resulted that there is a strong positive correlation between unhealthy attachment styles and being in border with an eating disorder.This means that teenage girls with unsecure, avoidant or disorganized attachment style show also higher predisposition to develop an eating disorder and teenage girls with secure attachment style will show lower risk to develop an eating disorder.The finding of this study makes us understand the importance of attachment processes in adolescents psychological well-being, in their mental health and how the presence of an unhealthy attachment style can be a risk factor of developing an eating disorder.

11.Recommendations
Therapists must be aware of the nature and manifestations of the symptoms of eating disorders and with te understanding of attachment style processes during their work with teenage girls.This will help therapists to a better understanding of the history of the concerns of the client as well to understand the real origin of the problem.Therapists who will work with this category of adolescents should take present that symptomatology of eating disorders derive also from unhealthy attachment styles (unsecured, avoidant, disorganized) and they work should focus on improving teenages styles of relating to others.
; Multidimensional eating disorder inventory -Garner, Olmstead & Polivy (1983) and The questionnaire of Demographic Data.Attachment Styles Inventory(Bartholomew 1991) : This instrument has been used widely in different studies of the categorization of attachment styles, respectively secure, unsecure, avoidant and disorganized attachment style.The instrument contains 30 claims related to the attachment styles.It was designed byBartholomew (1991) to measure attachment styles in adolescence and early adulthood.It is constructed according to the Likert-Scale from 1(totally not agree)-5(totally agree).Alfa Cronbach of this instrument in the current study resulted 0.85.Time managment of the instrument was 10-15 minutes.Allegations 3, 9, 10, 15, 28 belong to the secure attachment style, where 9 and 28 are reverse scored.Allegations 1, 5, 12, 24 belong to the unsecure attachment style.Allegations 6, 8, 16, 25, where 6 is reverse scored, belong to the disorganized attachment style.Allegations 2,19, 22, 26 belong to the avoidant attachment style.Multidimensional eating disorder inventory-Garner, Olmstead & Polivy (1983) :It is an instrument used on various studies to measure the symptomatology of eating disorders.Alfa Cronbach of this instrument in the current study resulted 0.9.This instrument measures the presence or not of an eating disorder.The instrument contains 40 claims related to the symptoms of eating disorders.The total of the point in this instrument are 120 points are.The instrument has been divided in three levels of points.Individuals who take from 0-29 points are categorized as normal and individuals who do not have symptoms of eating disorders and are not at risk to develop one.Individuals who take from 30-50 points are categorized as individuals who are in the border with eating disorders, they show symptoms and predisposition to develop an eating disorder.But individuals who take more than 50 points are categorized as individuals who already have an eating disorders

Table 2 .
data were analyzed with the Statistical Program for Social Sciences (SPSS) version 20.Statistics included in this basic program were correlations and descriptive statistics, such as : frequencies, averages, percentages, corss tabulations, rates etc.Out of the sample of 300 adolescents, 13 of fulfilled instruments resulted not valid, consequently results have been extracted from the final sample of 287 teenage girls.The results obtained from the Multidimensional eating disorder inventory-Garner, Olmstead & Polivy (1983) are presented in the following table : Results of "Multidimensional eating disorder inventory"

Table 2 .
The results expressed in percentages about the symptoms of eating disorders of teenage girls in the study.

Table 8
. Problems such as diet, food e weight control, disturbances about weight and body shape, and problematic relations with parents can be risk factors on developing an eating disorder in adolescence(Schupak-Neuberg et al.1993).Resulted that that form 287 teenage girls 22% of them had secure attachment style, 31.3% of them had insecure attachment style, 29.9% had disorganized attachment style and only 16.7% of them exhibit avoidant attachment style in relations with others.Resulted that the girls which did not exhibit eating disorders or predisposition to develop an eating disorders, have these attachment styles in their relationships with others : 32.3% have secure attachment style, 30.3% have insecure attachment, 25.6% the teenage girls which did not exhibit eating disorders or predisposition to develop an eating disorders have disorganized attachment style;11.8% of their have avoidant attachment style in establishing relations with others.Studies reported by Schupak-Neuberg et al.(1993), indicate that when teenage girls have an unhealthy attachment style, they become much more self-conscious.Self-awareness leads to increased high self-criticism, leaving adolescent girls extremely vulnerable to eating disorders (Schupak-Neuberg et al.1993).