Psychoneuroendocrinology (2015) 60, 39—45

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SHORT COMMUNICATION

Thinking of attachments reduces noradrenergic stress response Richard A. Bryant ∗, Lilian Chan School of Psychology, University of New South Wales, Sydney, NSW 2052, Australia Received 26 March 2015; received in revised form 6 June 2015; accepted 9 June 2015

KEYWORDS Attachment; Stress; Noradrenergic; Cortisol

Summary Although there is much evidence that activating mental representations of attachments figure is beneficial for psychological health and can reduce stress response, no research has directly investigated whether attachment activation can ameliorate hormonal stress response. This study investigated whether activating an attachment figure or a non-attachment figure following administration of a socially evaluated cold pressor test to elicit stress impacted on glucocorticoid and noradrenergic response. Participants (N = 61) provided baseline salivary samples, underwent a cold pressor test, then imagined an attachment or non-attachment figure, and finally provided subsequent saliva samples. Participants who imagined a non-attachment figure had greater noradrenergic response following the stressor than those who imagined an attachment figure. These findings highlight that activating attachment representations can ameliorate the immediate noradrenergic stress response. © 2015 Elsevier Ltd. All rights reserved.

Environmental stressors place enormous demands on our health and well-being (Schnurr and Jankowski, 1999), and can adversely affect key physiological responses such as immunological (Stam, 2007; Vidovic et al., 2011) and neural (Shin and Liberzon, 2010) functioning. Human stress response is underpinned by core stress hormones, which involve the fast-acting autonomic nervous system (which triggers noradrenergic response, leading to increased heart and respiration rate) and the slower-acting hypothalamicpituitary-adrenal (HPA) axis (which elicits glucocorticoid response, which in turn down regulates the sympathetic

∗ Corresponding author. Tel.: +61 2 9385 3640; fax: +61 2 9385 3641. E-mail address: [email protected] (R.A. Bryant).

http://dx.doi.org/10.1016/j.psyneuen.2015.06.004 0306-4530/© 2015 Elsevier Ltd. All rights reserved.

arousal) (Tsigos and Chrousos, 2002). Given the importance of the stress response to clinical disorders, such as posttraumatic stress disorder (PTSD), it is important to understand factors that moderate these key stress hormones. Seeking proximity to social attachments is one of the core strategies humans use to cope with stressful experiences. Attachment theory posits that humans, as well as many other species, programmed from an early age to seek refuge in trusted others in times of need; whereas this will initially be primary care-givers, others will assume this role as the organism develops (Mikulincer et al., 2005a). Consistent with this proposition, individuals seek attachments when they are presented with real or symbolic threats, and these supportive figures provide comfort during stress (Epstein and Meier, 1989; Mikulincer et al., 2002; Mikulincer and Shaver, 2007). For example, under conditions of threat

40 individuals have faster reaction times in recognizing the names of their secure attachment figures (Mikulincer et al., 2002). Supporting this theory is convergent evidence that having close social relationships can reduce stress level, promote subjective wellbeing and decrease vulnerability to serious illnesses (Cohen, 2004; House et al., 1988; Kaplan and Kronick, 2006). Evidence from experimental studies demonstrates that social support also reduces physiological pain experience (Brown et al., 2003; Jackson et al., 2005), participants’ pain ratings during painful thermal stimulation (Master et al., 2009), and pain-related neural activation (Eisenberger et al., 2011). Inherent in attachment theory is that one develops mental representations of these attachment figures, which can then serve similar functions in providing comfort during stressful experiences (Mikulincer et al., 2005a). Attachment theory also posits that when attachment representations are activated, people experience a wide range of psychological benefits. People who have generally secure attachments tend to report greater ability to cope with stress (Berant et al., 2001), and are even less likely to develop posttraumatic stress disorder (PTSD) after trauma exposure (Dekel et al., 2004). At an experimental level, activating attachment figures leads to less attentional bias to threat (Mikulincer et al., 2002). Moreover, priming attachment representations by (e.g. mother holding a baby) leads to a range of psychological benefits, including attributing positive attributes to neutral events (Mikulincer et al., 2001a). There is also evidence that activating representations of attachment reduces pain and pain-related neural activation (Eisenberger et al., 2011). Taken together, this evidence supports the theory that internal representations of attachment can alleviate psychological and neural reactions to aversive stimuli and enhance positive affect. The impact of attachment availability appears to be moderated, however by individual differences in how people seek attachments in response to stress. Attachment theories posit that prior experiences of unreliable relationships lead to differences in how are able to benefit from attachments. Specifically, it is proposed that early experiences of unavailable attachment figures result in people either excessively seeking attachments because they fear this support will not be provided or they may avoid attachments because they have learnt that they do not provide support during times of stress (Mikulincer et al., 2005b). Accordingly, attachment theories posit that during stress people with avoidant attachment tendencies distance themselves from attachments as a means of coping (i.e. hypoactivate the attachment system), whilst those with anxiety attachments tend to hyperactivate their attachment needs and seek out attachments (Mikulincer and Shaver, 2007). Supporting this proposal is evidence that during threat avoidantly attached individuals inhibit proximity-seeking behaviour and are less likely to activate attachment representations (Mikulincer et al., 2005a). Relatedly, there is evidence that individuals with severe anxiety, such as chronic posttraumatic stress disorder following prisoner of war experiences, do not experience the benefits of attachment priming, which suggests that these individuals may also lack the appropriate secure attachment systems that can benefit from attachment activation (Mikulincer et al., 2014).

R.A. Bryant, L. Chan To date there is no evidence regarding the impact of activating attachment representations on core psychophysiological stress responses. If attachment representations do in fact ameliorate stress reactions, one would expect them to reduce fundamental biological reactions to threats. To study the impact of attachment representations on human stress response, we studied the effects of either an attachment or non-attachment prime following a stressor on both noradrenergic and glucocorticoid response. We administered the attachment/non-attachment prime following a cold pressor test, which was employed because it induces marked stress reactions that include increased glucocorticoid and noradrenergic response (Bryant et al., 2013; Cahill et al., 2003). Accordingly, this paradigm allowed us to test the extent to which activating attachments can alleviate core stress responses. We hypothesized that the attachment prime would result in reduced noradrenergic and glucocorticoid response to the stressor relative to the non-attachment prime, however that this effect would be less evident in participants with an avoidant attachment style because of their tendency to not hyperactivate attachment systems in response to threat.

1. Methods 1.1. Participants Participants were 61 healthy undergraduate students (mean age, 20.18 y; SD, 1.23 y) who participated in return for course credit. Participants scored below ‘severe’ levels on scales of the Depression, Anxiety and Stress Scale (DASS) (Lovibond and Lovibond, 1995). The study was approved by the University of New South Wales School of Psychology Ethics Review Committee, and all participants gave written informed consent. Participants were randomized to either the attachment (n = 32; 15 males, 17 females or nonattachment prime conditions (n = 29; 11 males, 18 females).

1.2. Procedure Participants were instructed not to exercise for 24 h nor consume caffeine or alcohol 3 h prior to the study. To control for diurnal changes in cortisol levels, all testing occurred between 13.00 and 18.00 h, and each experimental session was conducted by a female experimenter. Participants initially completed the DASS to measure anxiety and depression. Participants were then asked to nominate either attachment or non-attachment figures. Participants in the Attachment Condition were asked to describe a relationship with a person who was very supportive and those in the non-attachment condition were asked to describe someone they knew who but were not personally close to; participants overwhelmingly nominated a direct family member as the attachment figure. To minimize the possibility that nominating the attachment figure may preemptively activate attachments prior to the administration of the stressor, 20 min were then devoted to administration of further questionnaires and collection of saliva. Specifically, the Experiences in Close Relationships scale (ECR) (Brennan et al., 1998) was administered to assess anxious attachment and avoidant attachment styles. The ECR is a

Attachment and stress 36-item self-report scale that comprises two subscales: anxious attachment and avoidant attachment, with each item is scored on a 7-point Likert scale. Participants then completed the Vividness of Visual Imagery Questionnaire (VVIQ), which consists of 16 items that involves imaging a specific scene and from which imagery ability is scored (Marks, 1973); the VVIQ was used to ensure that participants in both conditions had comparable capacities in imagining the attachment/non-attachment primes. Participants then provided an initial saliva sample from which baseline levels of sAA and cortisol were measured. Salivary cortisol was assayed to measure glucocorticoid response and salivary alpha amylase (sAA) was measured as it has been shown to be a biomarker of noradrenergic response (Nater and Rohleder, 2009). Following previous studies that have demonstrated elevated cortisol provocation (Cahill et al., 2003), participants were then administered the SECPT, which involved placing their left forearm in a bucket of ice water (3 ◦ C) for a period of 90 s. If participants removed their arm from the water prior to the 90 s, they were instructed to replace it immediately (all participants complied with this task). They were instructed that they would be evaluated by experts on their performance via a videorecording system that was operating through a cold pressor test (a modified Socially Evaluated Cold Pressor Test; SECPT (Schwabe et al., 2008)). This procedure is known to elicit physiological arousal (Cahill et al., 2003). In a variation to the standard SEPCT, although participants received these instructions during the videoing of the cold pressor test, their responses were not actually evaluated and they did not receive direct feedback about their performance. Immediately following removal of the arm from the ice water, participants were instructed to imagine the attachment or non-attachment figure they had previously nominated. Participants were told to imagine that person for a period of 60 s. Following this, participants were asked to rate how vivid the imagery was that they had experienced (1 = not at all, 7 = extremely) and how supported they felt whilst imagining the person (1 = not at all, 7 = extremely). To allow comparison with baseline hormonal levels (Cahill et al., 2003), a second saliva sample was then obtained to assess sAA levels, and after a period of rest of 15 min a final saliva sample was taken to assess cortisol levels; this time delay was used because peak cortisol levels are reached 15—20 min after the stressor (Kudielka et al., 2009). Finally, participants were debriefed about the study goals and the study terminated.

1.3. Salivary data analysis Endogenous stress hormones were indexed via saliva sampling using the passive drool method (without induction), which required participants to fill a self-collection container with 10 ml of saliva. All saliva samples were stored frozen at −20 ◦ C for 5 days until assay, underwent one freeze/thaw cycle, and were centrifuged at 1500 × g. Salivary alpha amylase (sAA) was measured as it has been shown to be a sensitive biomarker of sympathetic or parasympathetic nervous system activity (Nater and Rohleder, 2009). Saliva analyses were performed at Stratech Scientific APAC (Sydney, Australia;

41 http://www.stratechscientific.com.au/). Thawed and centrifuged saliva samples were diluted 1:200 by first diluting samples 1:10 with the ␣-amylase diluent provided, followed by a 1:20 dilution of the 1:10 diluted sample. This resulted in a final dilution of 1:200. In terms of cortisol, the concentration of cortisol for each sample is determined by interpolation from a standard curve generated by plotting cortisol standards (0.12—3.0 ␮g/dL) against their average OD divided by the background OD (B/o). The inter- and intraassay variability, respectively, was 5.8% and 6.5% for sAA, and 4.9% and 5.3% for cortisol, respectively.

2. Results 2.1. Participant characteristics Table 1 presents the participant characteristics according to attachment prime condition. Separate one-way analyses of variance (ANOVAs) revealed no pre-existing differences between conditions in age, or scores on the DASS-21, ECR or VVIQ. Further, there were no differences between conditions in baseline sAA and cortisol levels.

2.2. Manipulation check To index the extent to which the attachment primes achieved their intended goal, planned comparisons of the vividness and supportiveness ratings were conducted with an adjusted Bonferroni alpha of p < 025 (see Table 1). Whereas participants receiving the attachment prime reported feeling significantly more supported than those in the nonattachment prime [t(59) = 13.77, p < 001], the attachment prime resulted in only marginally more vivid imagining than the non-attachment prime [t(59) = 2.18, p = 0.04].

2.3. Stress hormone response The primary outcomes were noradrenergic and cortisol levels prior to and following the SECPT. Separate ANOVAs were conducted on sAA and cortisol, respectively (see Fig. 1). In terms of sAA, a 2 (Attachment Condition) × 2 (Assessment Period) repeated measures ANOVA indicated no significant main effects for Assessment Period [F(1, 59) = .01, p = 92,  = .00] or Attachment Condition [F(1, 59) = .09, p = 77,  = .001], but there was a significant interaction effect [F(1, 59) = 4.94, p < .05,  = .07]. Specifically, participants who were primed with attachment experienced a reduction in sAA following the stressor relative to those who were primed with non-attachment figures [t(59) = 2.12, p = .03]. A comparable 2 (Attachment Condition) × 2 (Assessment Period) repeated measures ANOVA of cortisol levels indicated no significant main effects for Assessment Period [F(1, 59) = .001, p = 97,  = .00], Attachment Condition [F(1, 59) = .03, p = 89,  = .001], or interaction [F(1, 59) = .16, p = 39, ␩ = .007] effects. To determine the potential role of attachment style on the influence of attachment prime, we conducted linear regression analyses of changes in cortisol and sAA from baseline levels to post-stressor levels. Anxious and avoidant attachment style were entered at Step 1, and attachment

42 Table 1

R.A. Bryant, L. Chan Participant characteristics.

Age DASS Depression Anxiety Stress ECR Anxious Avoidant VVIQ Baseline sAA (U/mL) Baseline cortisol (ug/dL) Post-attachment vividness Post-attachment supportiveness ratinga

Attachment (n = 32)

Non-attachment (n = 29)

20.19 (1.05)

20.17 (.93)

3.59 (2.86) 2.63 (2.52) 5.41 (3.97) 66.00 51.72 55.31 96.03 .21 5.75 6.28

(21.36) (19.08) (11.13) (51.83) (.13) (1.11) (.68)

3.79 (2.77) 2.45 (2.40) 5.17 (2.73) 69.93 52.93 61.86 85.29 .23 5.03 2.31

(18.85) (13.68) (15.28) (47.92) (.19) (1.45) (1.46)

Note. DASS, Depression Anxiety Stress Scale; ECR, Experiences in Close Relationship Scale; VVIQ, Vividness of Visual Imagery Questionnaire. Standard deviations appear in parentheses. a Indicates statistically significant difference between conditions.

Figure 1 Mean sAA and cortisol levels prior to and following stressor according to attachment prime condition. sAA was assessed at baseline and immediately post-SECPT. Cortisol was assessed at baseline and 15 min post-SECPT.

prime condition was entered at Step 2. There were no significant predictors of cortisol change. Neither anxious nor avoidant attachment style predicted change in sAA level, however after controlling for these factors priming an attachment figure accounted for 28% of the variance of decreased sAA following the stressor (B = .28, SEB = .14, ˇ = .26, p = .04).

3. Discussion Although attachment theory proposes that real or imagined proximity to an attachment figure provides security (Mikulincer et al., 2005a), and despite the very strong evidence that mental representations of attachments elicit positive psychological outcomes (Mikulincer et al., 2005b), the specific physiological mechanisms have not been well articulated. We found that participants who imagined an attachment figure immediately following a painful stressor displayed less noradrenergic increase than those who imagined someone who was not an attachment figure. The

current findings accord with evidence that experimental provision of attachment figures decreases attention to threat (Mikulincer et al., 2002), pain-related neural activation (Eisenberger et al., 2011), and a range of other psychological benefits (Mikulincer et al., 2001b). The key addition of the present study is that it points to how a core stress response is impacted by imagining an attachment figure. The observation that imagining an attachment figure ameliorated noradrenergic response following exposure to the stressor underscores one mechanism by which attachment may promote better coping with threats. Previous evidence has found that the stress response is moderated by actual social support (Kirschbaum et al., 1995), and that this effect is notable in those with secure attachment styles (Ditzen et al., 2008). Although there is a conceptual overlap between actual and imagined social support, the current finding is novel because it shows that activating attachment representations can buffer stress hormones. Acute stress triggers rapid activation of the locus coeruleus-mediated noradrenergic system, which results in a range of reactions

Attachment and stress that permit an immediate fight/flight response to threats (Bremner et al., 1996). The finding that attachment representation led to a reduction in this increase relative to a non-attachment representation points to attachment representations buffering the initial biological response to stress. There is convergent evidence that pharmacological blockade using noradrenergic antagonists (Hurlemann et al., 2010) can reduce noradrenergic activation after stress, however this finding is novel insofar as it shows that comparable effects can be found with attachment representations. We qualify this interpretation, however, with evidence that sAA may not reflect noradrenergic response as much as an indicator of autonomic nervous system activity (Ehlert et al., 2006). Contrary to our hypotheses, we did not find that the impact of the attachment prime was moderated by attachment style. This result is inconsistent to a degree with prior reports that avoidantly attached individuals are less prone to activate attachments in response to threats (Mikulincer et al., 2000, 2002, 2009), and also with findings that people with insecure attachments can benefit from the buffering effects of attachments in the face of stressors (Ditzen et al., 2008). It is possible that attachment style did not moderate outcomes in this study because we used a healthy college population that may have enjoyed generally secure attachment styles. This possibility is supported by the mean scores on the ECR subscales, which suggest that most participants did report generally secure attachment styles (Brennan et al., 1998). Unexpectedly there was no increase in cortisol levels following the SECPT; further, the attachment prime did not affect cortisol levels. The lack of association between these variables and cortisol is not consistent with previous reports that cortisol is increased following the SECPT (Cahill et al., 2003) and that attachment manipulations can alter cortisol (Ditzen et al., 2008). Cortisol level were obtained 15 min following the stressor; whereas some guidelines suggest that peak cortisol levels are achieved 15—20 min after a stressor (Kudielka et al., 2009), others suggests that peak levels are more likely to be achieved between 20 and 30 min (Hellhammer et al., 2009); it is possible that cortisol collection in the current study may not have allowed sufficient time for the peak cortisol levels to be achieved. Also, our variation to the SECPT such that experts did not actually view and evaluate performance on the cold pressor test may have reduced the stressful nature of the task. Moreover, given that we recognize that given that we did not observe changes in cortisol levels, and also the possibility that sAA levels may reflect autonomic nervous system response, it is possible that the observed differences may not be fully attributed to differential stress responses. We recognize some methodological limitations of these studies. First, we did not index distress in response the stressor and attachment primes, and so we can extrapolate from the physiological responses observed in these findings to experiential reactions to the attachment manipulation. Second, our sample sizes were relatively small which precluded consideration of differential impact of sex, which has been shown to moderate stress response (Andreano et al., 2008), including the moderating effects of social support (Engert et al., 2014). The potential role of sex differences is particularly relevant in light of evidence that social

43 support reduced men’s cortisol response if supported by a woman, however it increased cortisol response in women if supported by a man (Kirschbaum et al., 1995). This study employed standard attachment stimuli for participants of both sexes, and so this may have obscured sex-specific effects of the attachment stimuli for different participants. Further, the sex of the experimenter was female for all participants, which can also affect stress responses (Duchesne et al., 2012). Finally, improvements could have been made to our salivary analyses. We did not index salivary flow which can impact outcomes because sAA concentration reflects the accumulation of both salivary flow rate (which reflects parasympathetic response) and protein secretion (which is primarily sympathetic) (Bosch et al., 2011). Moreover, by only obtaining two saliva samples we risk not optimally indexing peak sAA and cortisol levels because of interindividual variation in peak responses; future studies should obtain approximately six samples to ensure peak responses can be assessed. In summary, attachment representations appear to reduce physiological stress responses, at least at the early stage of the stress response. The findings that the fast-acting noradrenergic response can be moderated by imagining an attachment figure points to core mechanisms for why attachments are beneficial in the context of threats. Given the evolutionary value of social interactions for responding to stressors, it seems adaptive that this influences of attachment on stress responses have developed. From an applied perspective, these results point to the potential of activating attachment representations in the aftermath of stress to facilitate adaptive response to the stressor. It is possible that activating attachment primes may be beneficial to augment treatment of those suffering from stress-related conditions, such as posttraumatic stress disorder, although given preliminary evidence that trauma sufferers may not benefit from attachment activation (Mikulincer et al., 2014), there is a need for further research into the beneficial effects of attachment representations in clinical populations.

Role of funding source This project was funded by an Australian Research Council Laureate Fellowship to R.A.B. (FL0992334). The Australian Research Council had no further role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflicts of interest No authors are declaring a conflict of interest.

Acknowledgements There are no additional acknowledgements.

44

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Thinking of attachments reduces noradrenergic stress response.

Although there is much evidence that activating mental representations of attachments figure is beneficial for psychological health and can reduce str...
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