Attachment theory suggests that different attachment styles influence the development of individual's self-esteem and modulate the individual's ability to manage stressful events by responding with adequate affective adjustment. High levels of insecure attachment are present in adults with Eating Disorders (EDs).

The variables that mediate the association between attachment style and EDs have not been investigated enough. The possibility exists that the endogenous stress response system is involved.

To appraise the role of the endogenous stress response system, we studied the effect of attachment styles on the hypothalamus-pituitary-adrenal (HPA) axis functioning in ED patients.

Fifty- two women with EDs and 25 healthy women completed the ECR questionnaire to assess their attachment style. Saliva samples were taken in the morning to measure the Cortisol Awakening Response (CAR). Moreover, the saliva cortisol response to the Trier-Social-Stress-Test (TSST) was measured in 30 ED patients and 15 healthy controls.

Patients with avoidant attachment showed an increased CAR compared to both healthy controls and to patients with anxious and secure attachment styles. In the initial TSST phase, cortisol levels decreased in the secure attachment group but not in patients with avoidant attachment. In the TSST stress response phase, the cortisol raise was higher in insecure patients and delayed in avoidant ones.

In adults with EDs, attachment styles affect the HPA axis functioning and this could have a role in the pathophysiology of EDs.

The authors have not supplied their declaration of competing interest.