br Table br Results from the multiple linear
Results from the multiple linear regression models of the relationship between attachment anxiety, attachment avoidance, demoralization, and depression (N = 382).
Predictors βa 95% CI p βa 95% CI p
Attachment anxiety subscale
Attachment avoidance subscale
a Standardized regression coeﬃcients.
coherent with the association between the perceived loss of autonomy and dignity in cancer patients , the association of these states with demoralization [33,34], and with requests for medical assistance in dying .
Attachment security was found to moderate the association of physical symptom burden and demoralization in the present study. This finding provides support for the view that individuals with less at-tachment security have less adaptive resources available to deal with the existential losses and fears that can result from the diagnosis and progression of advanced disease. By contrast, when individuals have an
inner working model that others will be supportive in times of need, a high physical symptom burden may be less likely to undermine their sense of meaning and hope. The mediating eﬀect of social support on the association of attachment security and Compound 48/80 reported by Rodin et al.  indicates that securely attached individuals may be better able to seek and receive support. Although the latter study also found an interaction eﬀect of attachment anxiety and physical symptom burden on depression, this eﬀect was not present for the physical symptom count index of the Memorial Symptom Assessment Scale, consistent with the present results for depression. Replication of the
Physical Symptom Burden
Physical Symptom Burden
Fig. 2. Association of physical symptom burden and demoralization for high and low levels of attachment anxiety (A) and avoidance (B). Attachment anxiety significantly moderated the association of symptom burden and demoralization.
S. Vehling et al.
discrepancy in the present study between the findings with depression and demoralization would strengthen the view that the buﬀering eﬀect of attachment security is specific to demoralization.
The strong negative relationship between attachment security and demoralization strengthens the likelihood that an attachment perspec-tive would be of value in existential interventions . Understanding a patient's attachment style may guide the stance of the therapist and aid in the identification of relational themes that can be addressed in the therapeutic context. In that regard, the renegotiation of attachment security is an important component of a psychotherapeutic intervention called Managing Cancer And Living Meaningfully (CALM ), which has been shown to be eﬀective in patients with advanced disease . Such renegotiation may support patients in their capacity to process and tolerate distress related to the requirement of increased de-pendency in this circumstance. Those with greater attachment anxiety benefit most from reliability and predictability in relationships with therapists and other health care providers, while those who are more avoidantly attached require greater support for their need to preserve their own sense of autonomy . Attachment security is also closely linked to the capacity to mentalize, which refers to the ability to dis-tinguish facts from feelings and to appreciate the possibility of multiple perspectives . Support for this imaginative process of perspective-taking is central to the CALM psychotherapy intervention [4,39]. r> From a theoretical perspective, the presumed role of attachment styles for adaptation to bereavement  may have value in under-standing adaptation to existential loss and death in advanced cancer . Attachment security may interfere with the ability to shift flexibly between facing the losses and threats of advanced cancer and con-tinuing to engage in meaningful activities in daily life, an experience that has been referred to as “middle knowledge”, the “living-dying-phase”, or “double awareness” [41–43]. Those with more attachment anxiety may be preoccupied with their fears of isolation and distress, impairing flexibility in life engagement, while those who tend to be more avoidant and self-reliant may have diﬃculty processing their grief and sharing their sense of loss with close others, impairing flexibility in loss orientation . In the context of a shortened life expectancy, the cultivation of such flexibility toward both orientations may support regulation of diﬃcult emotions and counter demoralization and its characteristic sense of being trapped and inability to imagine a per-sonally meaningful future.