Summary
Background
Interpersonal support is protective in heart disease, but sources of support and the quality of support may change over time, especially with aging and disease progression.
Aims
To determine if support received within an attachment relationship with a spouse is more protective than other types.
Methods
Subjects were sex- and age-matched cardiac outpatients with ( n = 40) or without ( n = 43) heart failure; they were studied with an observer-rated measure of attachment and self-report measures of other variables.
Results
Having heart failure was associated with more depressive symptoms and illness intrusiveness. Although perceived social support did not differ in people with or without heart failure, those with heart failure had a spouse as the primary source of attachment functions less frequently than those without heart failure (50% vs 79%; P = 0.006). Not having a spouse as the main provider of attachment functions was a partial mediator of the relationship between disease type (heart failure or no heart failure) and depressive symptoms ( β = –0.24, t = –2.2; P = 0.03) and deficits in non-attachment support made a further independent contribution ( β = –0.24, t = –2.4; P = 0.02). Neither perceived social support nor having a spouse serving attachment needs made a significant contribution to illness intrusiveness.
Conclusion
Having someone other than a spouse to provide attachment support is more common in cardiac patients who have heart failure and is associated with an increased risk of depressive symptoms.
Résumé
Contexte
Le soutien interpersonnel est un facteur de protection dans les maladies cardiaques. Néanmoins, les sources et la qualité du soutien peuvent changer progressivement, particulièrement avec le vieillissement et la progression de la maladie.
Objectif
Déterminer si le soutien d’un conjoint représente un facteur de protection plus élevé que le soutien d’un non-conjoint.
Méthodes
Les patients cardiaques non hospitalisés furent choisis selon leur sexe et leur âge, ainsi que l’existence ( n = 40) ou l’absence ( n = 43) d’insuffisance cardiaque. L’attachement fut évalué par des observateurs indépendants. Les autres variables furent obtenues via auto-évaluation.
Résultats
La présence d’insuffisance cardiaque était associée à plus de symptômes dépressifs et à une augmentation du caractère intrusif de la maladie. Le soutien social perçu n’a fait aucune distinction vis-à-vis l’insuffisance cardiaque, cependant ceux souffrant d’insuffisance cardiaque avaient moins souvent un conjoint comme la principale source de fonctions d’attachement (50 %) que ceux sans insuffisance cardiaque (79 % ; p = 0,006). L’absence d’un conjoint à titre de principal fournisseur de fonctions d’attachement était un facteur médiateur partiel entre le type de maladie (présence ou absence d’insuffisance cardiaque) et les symptômes dépressifs ( β = –0,24, t = –2,2 ; p = 0,03). Le manquement au soutient non attachement apportait aussi une contribution indépendante ( β = –0,24, t = –2,4 ; p = 0,02). Ni le soutien social perçu, ni la présence d’un conjoint répondant aux besoins d’attachement n’apportaient une contribution significative au caractère intrusif de la maladie.
Conclusion
Les patients cardiaques ayant une personne autre qu’un conjoint leur fournissant du soutient d’attachement ont plus souvent une insuffisance cardiaque et ont un risque plus accru de symptômes dépressifs.
Background
Interpersonal support includes emotional, tangible and informational support as well as social role engagement , and is a protective factor in heart disease, associated with lower incidence of coronary artery disease , fewer adverse events , increased longevity and better psychosocial function . The link between social relationships and illness is likely to be bidirectional; interpersonal interactions are affected by the progression of the disease, but also affect the course of the illness. Furthermore, the type of relationship in which support is received affects its quality. In particular, support that is received within an attachment relationship, such as from a spouse or committed romantic partner (hereafter referred to as ‘spouse’), may have a greater impact on health than support that is received from people in other types of relationships . The availability and quality of support from a spouse may change as couples age or as chronic illnesses in one or both partners progress. However, little is known about the impact of support from a spouse versus other types of support in people with heart disease.
The current study distinguishes general social support from attachment-related support. The latter concerns interpersonal functions that increase one’s sense of emotional security by providing an emotional ‘safe haven’ in times of distress and a ‘secure base’ from which to initiate independent activity . These functions are commonly provided by a spouse, although circumstances, including aging and disease progression, may lead a person to depend on others to provide attachment-related support. We also examine attachment type, a trait-like pattern of response to dynamic interactions in attachment relationships often categorized in four types: secure, dismissing, preoccupied and unresolved . Attachment type influences social support and is linked to a range of health outcomes, with secure attachment associated with better outcomes .
We hypothesize that the health benefits of support are diminished when a person with heart disease receives attachment-related support from a non-spouse. The consequences of cardiovascular disease that we studied were depressive symptoms, anxiety symptoms and diminished social/occupational function . We also explored if these relationships vary with sex, age and the presence or absence of heart failure (included as a final common pathway of many cardiac conditions and, therefore, a proxy marker for disease that has progressed further, to a more debilitating disease stage).
Methods
Participants
This study was a cross-sectional cohort comparison of two groups of outpatients treated for heart disease recruited from a larger study of 98 participants: adults with a confirmed diagnosis of heart failure (New York Heart Association class II or III; n = 40) recruited from cardiology clinics at a downtown hospital and a suburban teaching hospital; and age- and sex-matched cardiology patients without heart failure recruited from the downtown hospital ( n = 43). Subjects were included if they had completed each of the measures of global perceived social support, attachment type and role of the person who provides core attachment needs. All subjects provided written informed consent and the project was approved by the research ethics boards of both hospitals.
Instruments
Demographic and clinical information (including clinical diagnosis and left ventricular ejection fraction by echocardiogram) were obtained from medical records.
Perceived social support
The Medical Outcomes Study Social Support Scale (MOS-SSS) measures social support as the sum of availability (‘how often is each of the following types of support available…’) of informational-emotional support, tangible support, affectionate support and positive social interaction. Nineteen items that measure availability on a five-point Likert scale are summed. Cronbach’s alpha in this sample was 0.96.
Receiving attachment-support from a spouse or other person
The role of the person meeting core attachment needs was determined using the WHOTO scale, which was used previously in young adults to describe the transition from parents to peers and partners serving these functions . The WHOTO asks six questions, two for each attachment function, e.g. ‘who is the person you don’t like to be away from?’ (proximity-seeking), ‘who is the person you want to be with when you are feeling upset or down?’ (safe haven), and ‘who is the person you would want to tell first if you achieved something good?’ (secure base). If a spouse was indicated for either WHOTO question, that attachment function was attributed to the spouse. Thus, the WHOTO yielded three variables: the person who is the object of proximity-seeking, the provider of a safe haven and the provider of a secure base (spouse/other). To simplify the analysis we consolidated these three variables into a single measure, the primary person who serves attachment functions. If a spouse served two or more of the three attachment functions, then the primary attachment figure was designated as ‘spouse’. If a spouse provided zero or one attachment function, the primary attachment figure was indicated as ‘other’. The median number of WHOTO questions for which the spouse was nominated was six for people for whom the primary attachment figure was assigned to ‘spouse’ and zero for people for whom the primary attachment figure was classified as ‘other’.
Attachment type
Attachment type was classified into secure, dismissing, preoccupied and unresolved, using the Adult Attachment Projective Picture System (AAP). The AAP asks a person to describe a series of seven line drawings of attachment situations (e.g. a child and woman face each other, sitting on opposite sides of the child’s bed). The individual describes what the characters are thinking and feeling, what led up to the scene and what will happen next . Verbatim transcripts are scored by trained coders with respect to both content and narrative characteristics, and are then classified. The AAP was designed to yield the same classifications as the gold standard Adult Attachment Interview .
Secure attachment is characterized by evidence of valuing close relationships, actively seeking repair when a relationship is strained or disrupted and associating such relationships with emotional reciprocity and comfort.
In dismissing attachment, close relationships are devalued, and cognitive strategies that contain or distance negative emotions are used to disavow and diminish perceived threats.
In preoccupied attachment, close relationships are approached with fear of separation or rejection, containing or distancing cognitive strategies are lacking, and action to repair strains and disruptions is absent or ineffective.
Unresolved attachment is a pattern in which there is evidence of unresolved memories of interpersonal trauma and loss .
Previous studies have found an interjudge reliability for AAP classifications of 85–90% for four-group classification and 90–92% convergent validity with two-group (secure versus all other types) Adult Attachment Interview classifications . In the current study, AAP transcripts from the first 49 cases were classified blindly and independently by the originators of the AAP, Carol George and Malcolm West. Ten disagreements in the classification of the first 29 cases were resolved by consensus, and inter-rater agreement for the next 20 cases was 100% (overall interjudge reliability of 80%). The remaining cases were classified by one of these raters.
Depression and anxiety symptoms
The Hospital Anxiety and Depression Scale is a 14-item questionnaire that measures current anxiety (seven items) and depressive symptoms (seven items) in non-psychiatric hospital patients . Construct validity has been confirmed in patients with myocardial infarction, breast cancer and stroke . In this cohort, Cronbach’s alpha was 0.81 for anxiety and 0.76 for depression.
Social/occupational function
The Illness Intrusiveness Rating Scale probes the degree to which a health condition interferes with 13 domains of living: health, diet, work, active recreation, passive recreation, financial situation, relationship with partner, sex life, family relations, other social relations, self-expression, religious expression and community involvement. This scale has been used in several different chronic illnesses and shows adequate reliability and validity. Cronbach’s alpha scores of internal consistency reliability are high, ranging from 0.79 to 0.90 . Participants’ ratings of the degree to which their cardiac condition interfered with each domain on a seven-item Likert scale were summed. In this cohort Cronbach’s alpha was 0.90.
Analysis
Perceived social support can be provided by a spouse or by other people, but some of the MOS-SSS items overlap with attachment functions. In order to measure the impact of attachment-related support independent of generic non-attachment support, the perceived social support variable used was the residual variance in total perceived support score after regressing the dichotomous WHOTO variable (primary person who serves attachment functions – spouse or other) on the raw MOS-SSS total score, with the residual variance saved as a new variable, named non-attachment support.
Comparison of variables between age groups and disease condition groups (heart failure present/absent) were tested by analysis of variance or the χ 2 test, as appropriate. A mediation analysis, based on the methods of Baron and Kenny , was performed for dependent variables (depression, anxiety, illness intrusiveness) and potential mediators (receiving attachment function from a spouse, attachment type) that had a significant bivariate relationship with disease condition. Covariates (age, non-attachment support) were included if their relationship to dependent variables was at least near significance ( P < 0.1). Analyses were performed with IBM SPSS Statistics, version 22 (IBM, Armonk, NY, USA). Significance was set at P < 0.05 (two-sided).
Results
Participant characteristics are described in Table 1 . The prototypic participant was a male (72%) in his late sixties (mean age ± standard deviation, 68.7 ± 11.2 years) with coronary artery disease (53%). Fourteen subjects with heart failure (35%) had coronary artery disease compared with 30 subjects without heart failure (70%; P < 0.001).
| Variable | Patients without heart failure ( n = 43) | Patients with heart failure ( n = 40) | P |
|---|---|---|---|
| Age (years) | 67.7 ± 10.0 | 69.8 ± 12.4 | 0.39 |
| Women | 10 (23) | 13 (33) | 0.35 |
| Selected cardiac history | |||
| Coronary artery disease | 30 (70) | 14 (35) | < 0.001 |
| Hypertension | 18 (42) | 21 (53) | 0.33 |
| Valvular disease | 7 (16) | 8 (20) | 0.66 |
| Chronic treatments | |||
| ACE inhibitor | 18 (42) | 30 (75) | 0.002 |
| Amiodarone | 0 (0) | 7 (18) | 0.004 |
| Aspirin | 30 (70) | 19 (48) | 0.04 |
| Beta-blocker | 28 (65) | 38 (95) | 0.001 |
| Digoxin | 1 (2) | 15 (38) | 0.001 |
| Furosemide | 0 (0) | 43 (100) | <0.001 |
| Other diuretic | 11 (26) | 24 (60) | 0.002 |
| Nitrate | 1 (2) | 4 (10) | 0.14 |
| Statin | 34 (79) | 24 (60) | 0.06 |
| Vitamin K antagonist | 8 (19) | 17 (43) | 0.02 |
| Number of cardiac drugs | 3 (1–5) | 6 (3–8) | 0.001 |
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