1. Diane Elfleet3, Anne Darton7, John Vandervord1,3
Is attachment style associated with psychological symptoms in early adjustment to severe burn injury in adults?
Loyola McLean1-2, Julia Kwiet1,3-4, Vanessa Rogers1-2, Joanne Shaw5, Marie-Therese Proctor6, Jeremy Law1, Jeffrey Streimer1-2
Diane Elfleet3, Anne Darton7, John Vandervord1,3
Discipline of Psychiatry, SMS, University of Sydney
Consultation-Liaison Psychiatry, RNSH
Severe Burns Injury Unit (SBIU), RNSH
Social Work, RNSH
University of Sydney
Wesley Institute
Agency for Clinical Innovation

2. Background
Burn injury poses serious psychological and physical adjustment challenges.
Many factors influence coping.
The way patients accept and utilise help is an important factor in their recovery and rehabilitation journey.
The literature has noted that avoidance can be a significant problem.
Attachment style defines an individual’s level of comfort with seeking and receiving help,
Those comfortable with help are described as having a secure attachment style
Those who are uncomfortable with help described as having an insecure style.
Our clinical experience with psychosocial screening in a burn injury unit suggested that attachment style might be a significant factor in adjustment to burn injury. For a short talk on attachment double-click this icon
The study
Hypothesis: That a secure attachment style will:
Protect in psychosocial adjustment in early recovery from severe burn injury
Positively impact on early levels of posttraumatic, depression, anxiety and perceived stress symptoms.
This study formed part of the quantitative arm of our larger mixed methods study on Adjustment to Burns in adult patients.
We enrolled 104 adult cases, without current delirium or significant cognitive impairment, to complete questionnaires within the first 12 weeks following a burns injury.
Attachment style was assessed with 2 simple measures the :
Relationship Questionnaire (RQ), well known in the attachment self-report literature1
ABCD-Self Report (ABCD-SR), locally developed, based upon the ABCD Ainsworth-Main coding of attachment styles.2-3
Psychological symptoms were assessed with the:
Depression Anxiety and Stress Scale (DASS)4
Davidson Trauma Scale (DTS)5
Questionnaire returns gave a sample of n=51 for the RQ and n=49 for the ABCD-SR.
Within this sample we found a prevalence of RQ-defined security of 49% (25/51) and ABCD-SR defined security of 69.4% (34/49).  
Bartholomew, K. & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a four category model. Journal of Personality and Social Psychology, 61,
McLean L, et al, 2004, copyright
McLean L (2012). Psychodynamic Formulation: Aspects of Attachment and Development. Lecture 2, Session 18, in Phillips M, Streimer J, Shaw J (eds), The Complete Clinical Assessment in Psychiatry, Teaching Resource, HETI: Sydney, Complete Clinical Assessment in Psychiatry.pdf
Lovibond, S.H.& Lovibond, P.F. (1995) Manual for the Depression Anxiety Stress Scales. Sydney: The Psychology Foundation of Australia Inc.
Davidson, JR et al (1997). Assessment of a new self-rating scale for post-traumatic stress disorder. Psychological Medicine, 27 (1),

3. Associations of attachment with psychological symptoms
After removing outliers and checking for normality, first-pass hypothesis tests with independent samples t-tests were significant:
1) those defined secure on the RQ had significantly lower mean total scores on the DASS and on the DST, with substantive effect size (Cohen’s d):
2) those defined secure on the ABCD-SR had significantly lower mean total scores on the DASS and on the DST, with substantive effect size (Cohen’s d):
Conclusions
Results suggest a protective association between security of attachment style and levels of psychological symptoms during the early post-burn injury adjustment period.
This work requires replication. Second phase of analysis will consider covariates of gender and TBSA.
We are including these attachment measures in baseline screening as we establish routine psychosocial outcome tracking in our burn injury patients at the SBIU.
Information on attachment style can also help burn teams consider how to engage an individual patient in rehabilitation (relational style) and may give some early indication of psychosocial risk.
Contact RQ
DASS
mean N SD t df
p-value
Cohen’s d
Secure
15.2 23
12.4
-3.74
31.99
0.001
-1.04
Insecure
42.4 26
34.7 RQ
DST
mean N SD t df
p-value
Cohen’s d
Secure
15.2 24
15.8
-3.28
35.06
0.002
-0.92
Insecure
40.5 26
35.7
ABCD-SRR
DASS
mean N SD t df
p-value
Cohen’s d
Secure
17.3 30
15.0
-3.7
14.78
0.002
-1.63
Insecure
57.6 14
39.5
ABCD-SRR
DTS
Mean N SD t df
p-value
Cohen’s d
Secure
16.1 31
15.7
-3.29
14.98
0.005
-1.44
Insecure
51.5 14
38.9