Researchers always strive to understand the association between attachment styles, body image concerns, and problematic eating attitudes and behaviors, including binge eating, restrained eating, emotional eating, and orthorexia.
Eating disorders (ED) are complex psychiatric illnesses characterized by body image dissatisfaction with severe medical consequences (1). They are associated with a marked deterioration in the quality of life and an impact on personal and social life (2, 3). Binge eating disorder (BED) is characterized by a loss of control to stop eating and by overeating and consuming large amounts of food in a short time, followed by overwhelming feelings of guilt (4). Restrained eating behavior (RE) is the intention to restrict dietary intake either to avoid weight gain or to lose weight (5, 6). Emotional eating is a common and problematic eating behavior in response to negative affect (7); emotional eaters usually eat more when they face negative emotions (8). Orthorexia Nervosa is characterized by an excessive preoccupation with eating healthy food that remained unclassified in the Diagnostic and Statistical Manual of Mental Disorders 5th edition (9). Orthorexic people remove from their diets foods they consider to be impure and worry about the materials used in food production (10). Eating attitudes are behaviors, feelings, and thoughts towards foods. Disordered eating are linked to a disturbance in eating attitudes (11). Disordered eating attitudes occur more in women and are more correlated with higher body weight (12) and body shape concern (13).
Attachment theory is a psychological model that provide an integrative approach for understanding and describing interpersonal relationships. Improving the functioning of the attachment contributes to positive effects in eating disorders treatment (14). Hazan and Shaver described three adult attachment styles (15). These include secure attachment and two types of insecure attachment: avoidant and anxious attachment. Secure attachment is a crucial protective factor of mental health and stable self-structure (16); it is characterized by self-confidence, independence, and an ability to interact with others. However, avoidant attachment pattern is usually dismissive of close relationships, and anxious attachment is described by an intense need to maintain close relationships with others. Attachment dysfunctions can contribute to self-disturbances (16, 17). Insecure attachment is linked to several negative outcomes, such as lower academic achievement, low self-esteem, and psychopathology, including disordered eating (18).
Different studies showed a positive correlation between insecure adult attachment and the expression and maintenance of unhealthy eating attitudes and behaviors (19) and eating disorders at both clinical and sub-clinical level (20–22). Insecure attachment was shown to be associated restraint eating (23) and binge eating (24). A systematic review of 154 studies showed that insecure attachment and negative self-image were highly correlated to eating disorders (25). In addition, Tasca et al. showed that 80–100% of individuals with eating disorders had insecure attachment (26). Indeed; unhealthy eating attitudes and behaviors were associated with insecure attachment (26–29). However the literature investigating the relationship between various styles of attachment and particular subtypes of eating disorders remains inconclusive (29, 30). Eating disorders, were linked to high attachment insecurity regardless of a specific style (26, 31). Furthermore, the various interactions between the two dimensions of insecure attachment (avoidant and anxious) and disordered eating were determined. Attachment anxiety and avoidance were respectively associated with binge eating and bulimic-spectrum disorders and restricting-type anorexia nervosa (32, 33). Restricted eating was seen as an effort to avoid the negative emotions, related to an emotional cut-off while binge eating was seen as a self-medication for distress with foods, related to an emotional reactivity (34–36). Orthorexia nervosa was shown to be correlated to negative body image attitudes, and insecure attachment and avoidant styles (37).
Insecure attachment is not sufficient to trigger alone the mental disorders (38), Researchers showed that the relationship between eating disorders and attachment styles can be mediated by body dissatisfaction (26, 39, 40). A meta-analysis study have showed that the indirect effect of insecure attachment on ED symptoms through body dissatisfaction yielded not significant effect size among ED samples (39). The indirect effect of body dissatisfaction were significant in studies with non-clinical population (72%) (39). A body image disturbance is linked to unhealthy eating attitudes and behaviors and is recognized as a risk factor for eating disorders (41). Insecure attachment was shown to be associated to body dissatisfaction (42) and higher weight concerns (43). Studies showed that girls with insecure attachments have a high level of negative body image, leading to thinness, disturbed eating patterns, bulimia, and eating disorders risk (44, 45). The positive correlation between binge eating, restraint eating and other eating disorders and body dissatisfaction were deeply discussed in literature (46–48). While the relationship between Orthorexia Nervosa and body dissatisfaction remained unclear. Some studies showed a positive correlation (49–51) while others reported the absence of this association (52–54).
Indeed insecure attachment and high body dissatisfaction were shown to be associated with eating disorders (55). Individuals with insecure attachment are more likely to express negative feelings about themselves and use dieting to achieve perfect body image, binge eating to improve their feelings and purging to avoid weight gain (34, 56, 57).
Almost the previous studies focused on the relationship between attachment style and eating disorders (26, 58), few of them reviewed the mediator role of body dissatisfaction linking insecure attachment to eating disorders (39).
Indeed, regarding the Lebanese populations, most of the studies discussed the prevalence of eating disorders (59), others determined the different factors associated with restrained eating, such as body dissatisfaction, eating attitudes, and adult attachment (60), or determined the effect of body dissatisfaction on orthorexia nervosa, binge eating, and restrained eating (61). In a previous study, Saade et al. showed that binge eating in Lebanese adults was correlated with the anxious attachment (62). Regarding orthorexia, studies showed its correlation with negative body image attitudes, as well as insecure attachment and avoidant styles (37). There is a lack of data within the Lebanese populations about the mediator role of the body dissatisfaction linking the relationship between eating disorders and attachment style. Based on all these information, this study aimed to check how the body dissatisfaction mediates the relationship between the attachment adult and disordered eating, thus contributing to a better understanding of maintained disordered eating (19). Based on previous studies (19, 21, 60, 63–77), a model has been specifically constructed for this study to evaluate the directional association between body dissatisfaction, adult attachment, and disordered eating (Fig. 1).