Psychology and Aging 2013, Vol. 28, No. 4, 1108-1114
© 2013 American Psychological Association 0882-7974/13/$ 12.00 DOI: l0.1037/a0034750
BRIEF REPORT
Associations Between Adult Attachment Characteristics, Medical Burden, and Life Satisfaction Among Older Primary Care Patients Helmut Kirchmann
Tobias Nolte
University Hospital, Jena, Germany
The Anna Freud Centre, London, Utiited Kingdom
Kristin Runkewitz
Lisa Bayerle, Simone Becker, Verena Blasczyk, Julia Lindloh, and Bernhard Strauss
Private Practice, Weimar-Schöndorf, Germany
University Hospital, Jena, Germany We investigated whether attachment security, measured by the Aduh Attachment Prototype Rating (AAPR), was correlated with life satisfaction, independent of sociodemographic characteristics, medical burden, and age-related coping strategies in a sample of 81 patients (69-73 years) reeruited from the register of a general primary care practice. Furthermore, we examined whether patients classified as AAPR-secure reported better adjustment to medical burden in terms of higher life satisfaction than did insecure patients. Attachment security was independently related to life satisfaction. Moreover, the association between medical burden and lower life satisfaction was significantly stronger for insecure than for secure participants. Our fmdings indicate that interventions to improve attachment security or coping processes related to attachment could help older adults retain life satisfaction. Keywords: attachment, successful aging, life satisfaction, somatic complaints. Adult Attachment Prototype Rating
People over 70 years of age experience pronounced losses in health (e.g.. Smith, 2001), as well as in locomotive, perceptual, and cognitive capabilities (e.g., Seidel et al., 2009). Such losses challenge aspects of the self-concept. Furthermore, the gap between personal capability and environmental demands widens. Individuals growing older must adjust to these losses to maintain life satisfaction. Fortunately, life satisfaction of older people remains remarkably stable, despite slight tendencies to decline (e.g., Gerstorf. Ram, Röcke, Lindenberger, & Smith, 2008). These findings suggest that individuals might potentially have resources enabling them to cope with physical constraints and losses of capabilities. From a developmental psychology perspective, the analysis of coping mechanisms should consider whether individual coping strategies enhancing Ufe satisfaction are associated with personahty traits. Evidence for this relationship should both improve the understanding
of interindividual differences in coping and provide a basis for the development of intervention strategies enhancing life satisfaction. Attachment theory provides a framework to relate experiences in close relationships to behavioral and cognitive processes of adjustment to danger, threat, and loss over the life span. Therefore, attachment theory might have the potential to link individual coping processes and life histories of elderly people. Attachment theory (Bowlby, 1969, 1973, 1980) assumes that humans have a primary need to establish a close relationship to one or a few caring persons (attachment figures). These relationships are vital to survival and crucial for psychological development in infancy and adulthood. The individual starts to internalize the experiences with attachment figures in early infancy and constitutes itmer working models (IWMs) of attachment that comprise expectations about others and evaluations of the self. The attachment system organizes behavior that establishes physical and/or emotional closeness to attachment figures, thus providing protection and comfort. It is activated in the face of danger, threat, and loss. If physical or emotional closeness has been established and the individual feels safe, the attachment system is deactivated. The counterpart of the attachment system is the exploration system, which focuses on the autonomous exploration of and assertiveness in the environment (Weinfield, Sroufe, Egeland, & Carlson, 2008). According to attachment theory, there are three classical types of IWMs: ambivalent, avoidant, and secure attachment. These appear as specific dispositions with regard to the shaping of close relationships and trigger type-specific emotional and behavioral responses in the face of threat, loss, and interpersonal stress (for an
Helmut Kirchmann, Institute of Psychosocial Medicine and Psychotherapy, University Hospital Jena, Friedrich Schiller University Jena; Tobias Nolte, The Anna Freud Centre, London, United Kingdom; Kristin Runkewitz, Weimar-Schöndorf, Germany; Lisa Bayerle, Simone Becker, Verena Blasczyk, Julia Lindloh, and Bernhard Strauss, Institute of Psychosocial Medicine and Psychotherapy, University Hospital Jena, Friedrich Schiller University Jena, Jena, Germany. Correspondence conceming this article should be addressed to Helmut Kirchmann, Institute of Psychosocial Medicine and Psychotherapy, Stoystrasse 3, D 07740 Jena, Germany. E-mail: [email protected]
1108
ADULT ATTACHMENT CHARACTERISTICS
overview, see Bretherton & Munholland, 2008). Securely attached individuals are characterized by a fiexible balance between the attachment and exploration systems. This balance enables them to be autonomous and to pursue their personal interests, but also to establish and maintain close, intimate relationships. When exposed to threat or loss, they cope appropriately with distress or seek support from attachment figures. Numerous studies have shown that attachment infiuences processes related to psychosocial functioning, life satisfaction, and well-being (e.g., Cassidy & Shaver, 2008). Panel studies have revealed that attachment insecurity in infancy is associated with decreased affect-regulation capacities (e.g.. Bosquet & Egeland, 2006), impaired social skills (Belsky & Fearon, 2002), negative self-evaluations (Sroufe, Egeland, Carlson, & Collins, 2005), and reduced problem-solving competencies (Schieche & Spangler, 2005) in later childhood. Furthermore, cross-sectional research using adult samples indicated correlations between attachment insecurity and dysfunctional attitudes (Reinecke & Rogers, 2001), maladaptive attributional style (Williams & Riskind, 2004), and lowered self-esteem and self-efficacy (Mikulincer & Shaver, 2007). Moderator effects have been found, indicating that attachment security is associated with better adjustment to disease (Gick & Sirois, 2010; Schmidt, Nachtigall, Wuethrich-Martone, & Strauss, 2002), experience in combat or imprisonment (Zakin, Solomon, & Neria, 2003), and becoming a crime victim or experiencing an accident (Perrier, Boucher, Etchegary, Sadava, & Molnar, 2010). Research investigating the role of attachment in older adulthood is relatively rare, although existing studies consistently show that attachment security is correlated with Ufe satisfaction (or self-reported well-being) among the elderly. Interpretations of these findings differ considerably. Some authors emphasize that attachment characteristics might be related to a real or perceived social support network (Gillath, Johnson, Selcuk, & Teel, 2011; Kafetsios & Sideridis, 2006; Merz & Consedine, 2009). Others highhght differences in emotion-regulation capacities (Wensauer & Grossmann, 1998), self-esteem (Hwang, Johnston, & Smith, 2009), ageism (Bodner & Cohen-Fridel, 2010), and general health (McWilliams & Bailey, 2010). However, causal infiuences remain tinclear. Most authors did not control for confounding variables and did not relate to specific concepts of research focusing on elderly people. Furthermore, data were usually crosssectional and based upon self-reports. In the current study, we used expert ratings for both the evaluation of the individuals' health condition (using the Cumulative Illness Rating Scale-Geriatric; CIRS-G; Hock & Nosper, 2005) and attachment characteristics (applying the interview-based Adult Attachment Prototype Rating; AAPR; Kirchmann, Fenner, & Strauss, 2007). We controlled for sociodemographic characteristics and assessed life satisfaction in an age-specific way: We assumed that secure attachment is a general personal resource that enables older adults to maintain their levels of life satisfaction and to adjust to health-related problems by different strategies (e.g., affect regulation, use of social support, problem-solving competencies). In line with theories of coping processes in response to major life changes and loss (e.g., Boemer & Jopp, 2007), we hypothesized that health-related problems impede achieving personal goals and, accordingly, infiuence life satisfaction. Thus, in addition to attachment, we assessed age-specific coping strategies related to pursuing personal goals in life, that is, tenacious goal pursuit and fiexible goal adjustment.
1109
More specifically, we addressed two research questions in a sample of primary care patients: First, we tested whether attachment security was correlated with life satisfaction, independent of sociodemographic characteristics, medical burden, and age-related coping strategies. Second, we examined whether securely attached participants exhibited more adaptive coping with medical burden (i.e., maintaining life satisfaction despite health problems) than did insecurely attached individuals.
Method Participants The sample consisted of 81 individuals (age range from 69 to 73 years) who were patients of the third author of this paper (K. Runkewitz) who is a general practitioner in Weimar, Germany (a city with about 60,000 inhabitants). All 244 patients in the practitioner's patient registry who were bom between 1937 and 1941 were contacted via mail and invited to participate in an interview study. It was explained that the interview would take place in the home of the patients and that their health statuses would be evaluated on the basis of the their medical records by the general practitioner. Of those 244 patients, 87 were willing to participate and underwent the assessment. From these, six participants had to be excluded (four interviews could not be assessed accurately; two patients did not complete the questionnaires).
Procedure The attachment interviews were carried out by four psychology students who had been trained by the principal investigator (who was not involved in conducting assessments). The duration of the interviews varied between 1 and 2 hr. Each interview was recorded on DVD. Following the interview, each participant was given a questionnaire and a prepaid envelope by which the questionnaire should be retumed by mail. Each participant received €20 as remuneration. The interview assessments were conducted by the four students who were blind to participants' questionnaire data and health status.
Measures Attachment. Degrees of attachment security as a continuous variable and attachment categories as a discrete variable (secure, ambivalent, or avoidant) were assessed using the interview-based AAPR (Kirchmann at al., 2007; Pilkonis, 1988; Strauss et al., 1999). A compendious description of the AAPR procedure is given by Strauss et al. (2006). Each interview was rated by two independent raters (in this study, the secure vs. insecure convergence between the raters was 88%). Following the independent ratings, raters had to conduct a case discussion yielding consensus ratings, which were used for data analyses. For the AAPR, high reliability estimates have been found and convergent, predictive (e.g., Strauss et al., 2006; Strauss, Mestel, & Kirchmann, 2011) and concurrent validity (Kirchmann at al., 2007) have been demonstrated. Medical burden. Patients' health status was assessed using the CIRS-G, (Miller et al., 1992; German adaptation from Hock & Nosper, 2005). CIRS-G scores result from expert ratings of individual health complaints with respect to 13 distinct organ systems (e.g., heart, vascular, hematopoietic, liver, pancreas, etc.). The
KIRCHMANN ET AL.
1110
ratings were based on information obtained by medical examination and/or from patients' medical records. In our study, the CIRS-G was assessed by the patient's general practitioner on the basis of the medical charts. Burden level in each organ system was rated on a 5-point ordinal scale according to a manual (Hock & Nosper, 2005). The composite score of the 13 organ systems yields a somatic morbidity index. In the current study, we squared each rating of the 13 organ systems before calculating the composite score to take the ordinal level of the scale into account. Coping with deficits and losses in later life. Age-specific coping was examined using the TenFlex self-report instrument (Brandtstädter & Renner, 1990). The TenFlex comprises 30 items (5-point Likert scale) that measure two conceptually orthogonal dimensions, flexible goal adjustment (Tenflex-Elexible) and tenacious goal pursuit (Tenfiex-Tenacious), each based upon 15 items. In a German study (Heyl, Wahl, & Mollenkopf, 2007), satisfactory rehability estimates were reported. A number of studies have demonstrated the construct validity of the TenElex scales, for example, showing that both coping strategies were positively related to measures of psychological well-being and negatively associated with physical complaints (for an overview see Henselmans at al., 2011). Life satisfaction. We used the Life Satisfaction Index (LSI), a multiitem self-report measure originally developed by Neugarten, Havighurst, and Tobin (1961). Wiendieck (1970) adapted a German version of the LSI, selecting 12 out of the original 20 items, all of which showed high reliability. In our study, we used a 4-point Likert scale that showed high intemal consistency in an earlier German study (Schmitz, Rothermund, & Brandtstädter, 1999), as well as criterion validity (negative correlations with critical life events, e.g., illness, financial problems, and family conflict). Furthermore, participants provided data on sociodemographic and psychosocial characteristics (e.g., age, gender, education, income, marital status, former occupational status, relationship status, having a pet). To obtain one value for socioeconomic status, we assessed education, status of former occupation, and net income per month, each by a 7-point ordinal scale, and then summarized it (according to Dulon, Bardehle, & Blettner, 2003).
Data Analyses Data analyses were carried out using IBM SPSS Statistics 19. Since otir sample was small, we decided to compute multiple regression
analyses in steps. We started with simple models and selected predictor variables for more complex models only if they accounted for more than 2% variance of life satisfaction. The moderator hypothesis was tested using traditional product-term analyses on the basis of z-transformed, respectively dummy-coded variables. In these multivariate analyses, we used one-tailed í tests for those regressors for which we assumed associations in a specific direction.
Results Assessed with the AAPR, 48 of the participants (59%) were categorized as secure, 11 (14%) as ambivalent, and 22 (27%) as avoidant. Theses frequencies were comparable to other nonpsychiatric samples assessed with the Adult Attachment Interview (AAI; Bakermans-Kranenburg & van IJzendoom, 2009). With respect to sociodemographics, 50 participants were women (31 men) with a mean age of M = 70.6 (SD = 1.35; range: 69-73); 45 participants were married, 10 unmarried, 20 widowed, and 6 divorced; 58 participants stated that they were in a relationship with a romantic partner (no relationship, 23); 54 participants were cohabiting with others, 26 lived alone (missing, 1); 26 participants had a pet (no pet, 55). Bivariate correlations are presented in Table 1. As expected, life satisfaction was positively correlated with the continuous attachment variable AAPR-Security, both TenElex variables, and the presence of a romantic relationship. Participants with greater disease burden (higher CIRS-G value) reported lower life satisfaction. Attachment security was positively correlated with tenacious goal pursuit. Medical burden (CIRS-G) was (negatively) correlated with life satisfaction. Furthermore, flexible goal adjustment was related to female gender, whereas tenacious goal pursuit was associated with male gender. Using multiple linear regression, we first analyzed whether the association between AAPR-Security and life satisfaction was robust, even if potential confounders were included in the models. In these and subsequent analyses, the dependent variable (life satisfaction) as well as the continuous regressors were z-transformed for better interpretability. In Model 1 (Ml), AAPR-Security was the only regressor for life satisfaction. In Model 2 (M2) sociodemographic/psychosocial variables were added to the model. As Table 2 shows, the inclusion of these variables did not significantly alter the regression coefficient of AAPR-Security on life satisfac-
Table 1 Pearson Correlations (Reliability Estimates in the Diagonal) Variable
LSI
AAPR-secure
Life Satisfaction Index AAPR-Security CIRS-G Tenfiex-Tenacious Tenflex-FIexible Socioeconomic Status Gender Relationship Having a pet
.83" .28* -.36** .24* .21 .10 -.08 .23* -.10
.84" -.07 .32* .01 .23* -.05 .35** -.04
CIRS-G
/ -.10 -.05 -.13
.09 -.09 .05
Tenfiex-Tenacious
Tenflex-FIexible
.79» .11 .44" -.17 .16 .02
.IT .04 .25* -.10 -.02
SES
.74° -.22*
.18 -.09
Gender
Relationship
/ -.33** .11
/ -.04
Note. AAPR = Adult Attachment Prototype Rating; CIRS-G = Cumulative Illness Rating Scale-Geriatric; coding of variables was Gender: male = 0, female = 1; Relationship means being in a relationship with a romantic partner: no = 0, yes = 1 ; Having a pet: no = 0, yes = 1; reliability estimates were not determined for CIRS-G, Gender, and Relationship. ° Cronbach's a. '' interrater reliability (ICC). * p < . 0 5 . **/7
© 2013 American Psychological Association 0882-7974/13/$ 12.00 DOI: l0.1037/a0034750
BRIEF REPORT
Associations Between Adult Attachment Characteristics, Medical Burden, and Life Satisfaction Among Older Primary Care Patients Helmut Kirchmann
Tobias Nolte
University Hospital, Jena, Germany
The Anna Freud Centre, London, Utiited Kingdom
Kristin Runkewitz
Lisa Bayerle, Simone Becker, Verena Blasczyk, Julia Lindloh, and Bernhard Strauss
Private Practice, Weimar-Schöndorf, Germany
University Hospital, Jena, Germany We investigated whether attachment security, measured by the Aduh Attachment Prototype Rating (AAPR), was correlated with life satisfaction, independent of sociodemographic characteristics, medical burden, and age-related coping strategies in a sample of 81 patients (69-73 years) reeruited from the register of a general primary care practice. Furthermore, we examined whether patients classified as AAPR-secure reported better adjustment to medical burden in terms of higher life satisfaction than did insecure patients. Attachment security was independently related to life satisfaction. Moreover, the association between medical burden and lower life satisfaction was significantly stronger for insecure than for secure participants. Our fmdings indicate that interventions to improve attachment security or coping processes related to attachment could help older adults retain life satisfaction. Keywords: attachment, successful aging, life satisfaction, somatic complaints. Adult Attachment Prototype Rating
People over 70 years of age experience pronounced losses in health (e.g.. Smith, 2001), as well as in locomotive, perceptual, and cognitive capabilities (e.g., Seidel et al., 2009). Such losses challenge aspects of the self-concept. Furthermore, the gap between personal capability and environmental demands widens. Individuals growing older must adjust to these losses to maintain life satisfaction. Fortunately, life satisfaction of older people remains remarkably stable, despite slight tendencies to decline (e.g., Gerstorf. Ram, Röcke, Lindenberger, & Smith, 2008). These findings suggest that individuals might potentially have resources enabling them to cope with physical constraints and losses of capabilities. From a developmental psychology perspective, the analysis of coping mechanisms should consider whether individual coping strategies enhancing Ufe satisfaction are associated with personahty traits. Evidence for this relationship should both improve the understanding
of interindividual differences in coping and provide a basis for the development of intervention strategies enhancing life satisfaction. Attachment theory provides a framework to relate experiences in close relationships to behavioral and cognitive processes of adjustment to danger, threat, and loss over the life span. Therefore, attachment theory might have the potential to link individual coping processes and life histories of elderly people. Attachment theory (Bowlby, 1969, 1973, 1980) assumes that humans have a primary need to establish a close relationship to one or a few caring persons (attachment figures). These relationships are vital to survival and crucial for psychological development in infancy and adulthood. The individual starts to internalize the experiences with attachment figures in early infancy and constitutes itmer working models (IWMs) of attachment that comprise expectations about others and evaluations of the self. The attachment system organizes behavior that establishes physical and/or emotional closeness to attachment figures, thus providing protection and comfort. It is activated in the face of danger, threat, and loss. If physical or emotional closeness has been established and the individual feels safe, the attachment system is deactivated. The counterpart of the attachment system is the exploration system, which focuses on the autonomous exploration of and assertiveness in the environment (Weinfield, Sroufe, Egeland, & Carlson, 2008). According to attachment theory, there are three classical types of IWMs: ambivalent, avoidant, and secure attachment. These appear as specific dispositions with regard to the shaping of close relationships and trigger type-specific emotional and behavioral responses in the face of threat, loss, and interpersonal stress (for an
Helmut Kirchmann, Institute of Psychosocial Medicine and Psychotherapy, University Hospital Jena, Friedrich Schiller University Jena; Tobias Nolte, The Anna Freud Centre, London, United Kingdom; Kristin Runkewitz, Weimar-Schöndorf, Germany; Lisa Bayerle, Simone Becker, Verena Blasczyk, Julia Lindloh, and Bernhard Strauss, Institute of Psychosocial Medicine and Psychotherapy, University Hospital Jena, Friedrich Schiller University Jena, Jena, Germany. Correspondence conceming this article should be addressed to Helmut Kirchmann, Institute of Psychosocial Medicine and Psychotherapy, Stoystrasse 3, D 07740 Jena, Germany. E-mail: [email protected]
1108
ADULT ATTACHMENT CHARACTERISTICS
overview, see Bretherton & Munholland, 2008). Securely attached individuals are characterized by a fiexible balance between the attachment and exploration systems. This balance enables them to be autonomous and to pursue their personal interests, but also to establish and maintain close, intimate relationships. When exposed to threat or loss, they cope appropriately with distress or seek support from attachment figures. Numerous studies have shown that attachment infiuences processes related to psychosocial functioning, life satisfaction, and well-being (e.g., Cassidy & Shaver, 2008). Panel studies have revealed that attachment insecurity in infancy is associated with decreased affect-regulation capacities (e.g.. Bosquet & Egeland, 2006), impaired social skills (Belsky & Fearon, 2002), negative self-evaluations (Sroufe, Egeland, Carlson, & Collins, 2005), and reduced problem-solving competencies (Schieche & Spangler, 2005) in later childhood. Furthermore, cross-sectional research using adult samples indicated correlations between attachment insecurity and dysfunctional attitudes (Reinecke & Rogers, 2001), maladaptive attributional style (Williams & Riskind, 2004), and lowered self-esteem and self-efficacy (Mikulincer & Shaver, 2007). Moderator effects have been found, indicating that attachment security is associated with better adjustment to disease (Gick & Sirois, 2010; Schmidt, Nachtigall, Wuethrich-Martone, & Strauss, 2002), experience in combat or imprisonment (Zakin, Solomon, & Neria, 2003), and becoming a crime victim or experiencing an accident (Perrier, Boucher, Etchegary, Sadava, & Molnar, 2010). Research investigating the role of attachment in older adulthood is relatively rare, although existing studies consistently show that attachment security is correlated with Ufe satisfaction (or self-reported well-being) among the elderly. Interpretations of these findings differ considerably. Some authors emphasize that attachment characteristics might be related to a real or perceived social support network (Gillath, Johnson, Selcuk, & Teel, 2011; Kafetsios & Sideridis, 2006; Merz & Consedine, 2009). Others highhght differences in emotion-regulation capacities (Wensauer & Grossmann, 1998), self-esteem (Hwang, Johnston, & Smith, 2009), ageism (Bodner & Cohen-Fridel, 2010), and general health (McWilliams & Bailey, 2010). However, causal infiuences remain tinclear. Most authors did not control for confounding variables and did not relate to specific concepts of research focusing on elderly people. Furthermore, data were usually crosssectional and based upon self-reports. In the current study, we used expert ratings for both the evaluation of the individuals' health condition (using the Cumulative Illness Rating Scale-Geriatric; CIRS-G; Hock & Nosper, 2005) and attachment characteristics (applying the interview-based Adult Attachment Prototype Rating; AAPR; Kirchmann, Fenner, & Strauss, 2007). We controlled for sociodemographic characteristics and assessed life satisfaction in an age-specific way: We assumed that secure attachment is a general personal resource that enables older adults to maintain their levels of life satisfaction and to adjust to health-related problems by different strategies (e.g., affect regulation, use of social support, problem-solving competencies). In line with theories of coping processes in response to major life changes and loss (e.g., Boemer & Jopp, 2007), we hypothesized that health-related problems impede achieving personal goals and, accordingly, infiuence life satisfaction. Thus, in addition to attachment, we assessed age-specific coping strategies related to pursuing personal goals in life, that is, tenacious goal pursuit and fiexible goal adjustment.
1109
More specifically, we addressed two research questions in a sample of primary care patients: First, we tested whether attachment security was correlated with life satisfaction, independent of sociodemographic characteristics, medical burden, and age-related coping strategies. Second, we examined whether securely attached participants exhibited more adaptive coping with medical burden (i.e., maintaining life satisfaction despite health problems) than did insecurely attached individuals.
Method Participants The sample consisted of 81 individuals (age range from 69 to 73 years) who were patients of the third author of this paper (K. Runkewitz) who is a general practitioner in Weimar, Germany (a city with about 60,000 inhabitants). All 244 patients in the practitioner's patient registry who were bom between 1937 and 1941 were contacted via mail and invited to participate in an interview study. It was explained that the interview would take place in the home of the patients and that their health statuses would be evaluated on the basis of the their medical records by the general practitioner. Of those 244 patients, 87 were willing to participate and underwent the assessment. From these, six participants had to be excluded (four interviews could not be assessed accurately; two patients did not complete the questionnaires).
Procedure The attachment interviews were carried out by four psychology students who had been trained by the principal investigator (who was not involved in conducting assessments). The duration of the interviews varied between 1 and 2 hr. Each interview was recorded on DVD. Following the interview, each participant was given a questionnaire and a prepaid envelope by which the questionnaire should be retumed by mail. Each participant received €20 as remuneration. The interview assessments were conducted by the four students who were blind to participants' questionnaire data and health status.
Measures Attachment. Degrees of attachment security as a continuous variable and attachment categories as a discrete variable (secure, ambivalent, or avoidant) were assessed using the interview-based AAPR (Kirchmann at al., 2007; Pilkonis, 1988; Strauss et al., 1999). A compendious description of the AAPR procedure is given by Strauss et al. (2006). Each interview was rated by two independent raters (in this study, the secure vs. insecure convergence between the raters was 88%). Following the independent ratings, raters had to conduct a case discussion yielding consensus ratings, which were used for data analyses. For the AAPR, high reliability estimates have been found and convergent, predictive (e.g., Strauss et al., 2006; Strauss, Mestel, & Kirchmann, 2011) and concurrent validity (Kirchmann at al., 2007) have been demonstrated. Medical burden. Patients' health status was assessed using the CIRS-G, (Miller et al., 1992; German adaptation from Hock & Nosper, 2005). CIRS-G scores result from expert ratings of individual health complaints with respect to 13 distinct organ systems (e.g., heart, vascular, hematopoietic, liver, pancreas, etc.). The
KIRCHMANN ET AL.
1110
ratings were based on information obtained by medical examination and/or from patients' medical records. In our study, the CIRS-G was assessed by the patient's general practitioner on the basis of the medical charts. Burden level in each organ system was rated on a 5-point ordinal scale according to a manual (Hock & Nosper, 2005). The composite score of the 13 organ systems yields a somatic morbidity index. In the current study, we squared each rating of the 13 organ systems before calculating the composite score to take the ordinal level of the scale into account. Coping with deficits and losses in later life. Age-specific coping was examined using the TenFlex self-report instrument (Brandtstädter & Renner, 1990). The TenFlex comprises 30 items (5-point Likert scale) that measure two conceptually orthogonal dimensions, flexible goal adjustment (Tenflex-Elexible) and tenacious goal pursuit (Tenfiex-Tenacious), each based upon 15 items. In a German study (Heyl, Wahl, & Mollenkopf, 2007), satisfactory rehability estimates were reported. A number of studies have demonstrated the construct validity of the TenElex scales, for example, showing that both coping strategies were positively related to measures of psychological well-being and negatively associated with physical complaints (for an overview see Henselmans at al., 2011). Life satisfaction. We used the Life Satisfaction Index (LSI), a multiitem self-report measure originally developed by Neugarten, Havighurst, and Tobin (1961). Wiendieck (1970) adapted a German version of the LSI, selecting 12 out of the original 20 items, all of which showed high reliability. In our study, we used a 4-point Likert scale that showed high intemal consistency in an earlier German study (Schmitz, Rothermund, & Brandtstädter, 1999), as well as criterion validity (negative correlations with critical life events, e.g., illness, financial problems, and family conflict). Furthermore, participants provided data on sociodemographic and psychosocial characteristics (e.g., age, gender, education, income, marital status, former occupational status, relationship status, having a pet). To obtain one value for socioeconomic status, we assessed education, status of former occupation, and net income per month, each by a 7-point ordinal scale, and then summarized it (according to Dulon, Bardehle, & Blettner, 2003).
Data Analyses Data analyses were carried out using IBM SPSS Statistics 19. Since otir sample was small, we decided to compute multiple regression
analyses in steps. We started with simple models and selected predictor variables for more complex models only if they accounted for more than 2% variance of life satisfaction. The moderator hypothesis was tested using traditional product-term analyses on the basis of z-transformed, respectively dummy-coded variables. In these multivariate analyses, we used one-tailed í tests for those regressors for which we assumed associations in a specific direction.
Results Assessed with the AAPR, 48 of the participants (59%) were categorized as secure, 11 (14%) as ambivalent, and 22 (27%) as avoidant. Theses frequencies were comparable to other nonpsychiatric samples assessed with the Adult Attachment Interview (AAI; Bakermans-Kranenburg & van IJzendoom, 2009). With respect to sociodemographics, 50 participants were women (31 men) with a mean age of M = 70.6 (SD = 1.35; range: 69-73); 45 participants were married, 10 unmarried, 20 widowed, and 6 divorced; 58 participants stated that they were in a relationship with a romantic partner (no relationship, 23); 54 participants were cohabiting with others, 26 lived alone (missing, 1); 26 participants had a pet (no pet, 55). Bivariate correlations are presented in Table 1. As expected, life satisfaction was positively correlated with the continuous attachment variable AAPR-Security, both TenElex variables, and the presence of a romantic relationship. Participants with greater disease burden (higher CIRS-G value) reported lower life satisfaction. Attachment security was positively correlated with tenacious goal pursuit. Medical burden (CIRS-G) was (negatively) correlated with life satisfaction. Furthermore, flexible goal adjustment was related to female gender, whereas tenacious goal pursuit was associated with male gender. Using multiple linear regression, we first analyzed whether the association between AAPR-Security and life satisfaction was robust, even if potential confounders were included in the models. In these and subsequent analyses, the dependent variable (life satisfaction) as well as the continuous regressors were z-transformed for better interpretability. In Model 1 (Ml), AAPR-Security was the only regressor for life satisfaction. In Model 2 (M2) sociodemographic/psychosocial variables were added to the model. As Table 2 shows, the inclusion of these variables did not significantly alter the regression coefficient of AAPR-Security on life satisfac-
Table 1 Pearson Correlations (Reliability Estimates in the Diagonal) Variable
LSI
AAPR-secure
Life Satisfaction Index AAPR-Security CIRS-G Tenfiex-Tenacious Tenflex-FIexible Socioeconomic Status Gender Relationship Having a pet
.83" .28* -.36** .24* .21 .10 -.08 .23* -.10
.84" -.07 .32* .01 .23* -.05 .35** -.04
CIRS-G
/ -.10 -.05 -.13
.09 -.09 .05
Tenfiex-Tenacious
Tenflex-FIexible
.79» .11 .44" -.17 .16 .02
.IT .04 .25* -.10 -.02
SES
.74° -.22*
.18 -.09
Gender
Relationship
/ -.33** .11
/ -.04
Note. AAPR = Adult Attachment Prototype Rating; CIRS-G = Cumulative Illness Rating Scale-Geriatric; coding of variables was Gender: male = 0, female = 1; Relationship means being in a relationship with a romantic partner: no = 0, yes = 1 ; Having a pet: no = 0, yes = 1; reliability estimates were not determined for CIRS-G, Gender, and Relationship. ° Cronbach's a. '' interrater reliability (ICC). * p < . 0 5 . **/7
