Research Article: Attachment Status Affects Heart Rate Responses to Experimental Ostracism in Inpatients with Depression

Date Published: March 4, 2016

Publisher: Public Library of Science

Author(s): Jannika De Rubeis, Stefan Sütterlin, Diane Lange, Markus Pawelzik, Annette van Randenborgh, Daniela Victor, Claus Vögele, Gabriel S. Dichter.


Depression is assumed to be both a risk factor for rejection and a result of it, and as such constitutes an important factor in rejection research. Attachment theory has been applied to understand psychological disorders, such as depression, and can explain individual differences in responses to rejection. Research on autonomic nervous system activity to rejection experiences has been contradictory, with opposing strings of argumentation (activating vs. numbing). We investigated autonomic nervous system-mediated peripheral physiological responses (heart rate) to experimentally manipulated ostracism (Cyberball) in 97 depressed patients with organized (n = 52) and disorganized attachment status (n = 45). Controlling for baseline mean heart rate levels, depressed patients with disorganized attachment status responded to ostracism with significantly higher increases in heart rate than depressed patients with organized attachment status (p = .029; ηp2 = .051). These results suggest that attachment status may be a useful indicator of autonomic responses to perceived social threat, which in turn may affect the therapeutic process and the patient-therapist relationship.

Partial Text

Social exclusion affects peoples’ psychological functioning and behavior. More precisely, it has been found to increase aggression [1–4], to decrement self-regulation [5], to threaten feelings of self-esteem, belonging, meaning, and control [6], to lead to social withdrawal, to physiological arousal, or to prosocial behavior [3]. Social exclusion is furthermore associated with the development of psychological disorders [7]. For example, the experience of social rejection has been proposed to play a prominent role in the onset and the maintenance of depression [8]. Early experiences of rejection by parents or peers, for example, are associated with internalizing problems [9] and with insecure attachment status that increase the risk for depression [10]. Rejection later in life has also been linked to depression [11]. Furthermore, interindividual differences in perceived rejection (i.e. rejection sensitivity), and hypervigilance for signs of rejection [12] are also predictors for depression.

This study investigated depressed inpatients’ cardiac reactivity after experienced social exclusion in relation to their organized or disorganized attachment status. We hypothesized that participants with a disorganized attachment status would show a more pronounced cardiac acceleration after being ostracized, compared to participants with organized attachment status. The present results confirm this hypothesis, in that HR changes were significantly higher in disorganized patients, even when controlling for age, gender and comorbid personality disorders. The results support Bernstein and Claypool’s severity hypothesis [86] on the direction of emotional reactivity, which contends that ostracism increases subsequent arousal. Attachment theory posits that early attachment experience plays an especially salient role in shaping developmental adaptation [110] and development of psychopathology. The mental representations rooted in the experiences between the child and the primary caregiver influence the later regulatory pattern (behavioral, emotional, cognitive, and physiological) in the face of stressors. In other words, the attachment relationship between child and caregiver gives rise to emotion regulation strategies, that can later develop to become risk factors for psychopathology [53; 58]). Therefore, the current results support the previously postulated hypothesis [111] that attachment theory could be extended to a biopsychosocial model of health that in turn, can explain some aspects of vulnerability to ill-health and gives rise to a range of hypotheses concerning behavior, cognition and affect. More precisely, (disorganized) attachment is hypothesized to form a diathesis that contributes to the (physiological) responses to social stress in individuals. The results are in line with our assumption that disorganization is associated with greater physiological arousal after perceived exclusion. Disorganized attached individuals lack adaptive emotion regulation skills [112], which promotes higher physiological arousal in a challenging situation. For patients with disorganized attachment status, a brief period of ostracism may activate negative self-schemata, leading to prolonged arousal and problems in self-regulation [113–115]. This (over-) interpretation of a minimal rejection episode as threatening one’s self, is likely to reinforce and strengthen the negative beliefs these patients hold about relationships [53], therefore increasing their sensitivity to exclusion experiences in future social interactions. Previous research [116] supports this notion of exacerbated perception of social cues of inclusion or exclusion, in that ostracism has the capacity to enhance the categorical (e.g., “all or nothing”) perception of social information. This forms a vicious circle, that may lead to a lowered, perceived threat threshold, which in turn gives rise to and reinforces the negative schemata the individual holds about him/herself, the world and the future [117]. Knowledge about the attachment status and incorporating strategies to buffer these consequences into the therapeutic processes may be helpful [118]. More precisely, this could be done by conveying information about the attachment system, challenging deep-seated schemata (e.g., through Socratic questioning), and helping to regulate physiological arousal (e.g., biofeedback techniques).

Social exclusion evoked a physiological response pattern that was–as hypothesized- characterized by heart rate increases. Depressed patients with a disorganized attachment status reacted with a more pronounced hear rate acceleration than their organized counterparts, supporting the difficulty of this patient group in regulating emotions and supports the hypothesis of disorganized attachment being a risk factor for ongoing or a relapse to depression after being socially excluded.