Avoidant Attachment Style Moderates the Recovery of Healthy Sexuality in Women With Anorexia Nervosa Treated With Enhanced Cognitive Behavior Therapy (CBT-E): A 2-Year Follow-Up Study

Background: Insecure Attachment style has been associated with interpersonal problems in persons with Anorexia Nervosa (AN), and it might moderate the recovery of healthy sexuality in these subjects.

Aim: The aim of the present 2-year follow-up study was to evaluate the role of insecure attachment style as a moderator of the recovery of healthy sexuality in women with AN.

Methods: 63 Italian women with AN treated with a multidisciplinary approach including Enhanced Cognitive Behavior Therapy were evaluated by means of a clinical interview and self-administered questionnaires. Individual psychotherapy sessions were administered by experienced psychotherapists over the course of at least 40 weeks (median number of sessions = 43, range: 38-50); trained dieticians provided personalized nutritional counselling to facilitate weight recovery. The assessment was performed at baseline (T0) and after 1 (T1) and 2 (T2) years.

Outcomes: The administered questionnaires investigated general psychopathology (SCL-90-R), eating disorder-specific psychopathology (EDE-Q), female sexuality (FSFI) and adult attachment style (ECR).

Results: At baseline, avoidant attachment style was associated with all domains of sexual dysfunction. Longitudinal analysis showed a significant decrease in both eating disorder-specific psychopathology and sexual dysfunctions at follow-up evaluations. However, only 45% of remitted subjects also recovered healthy sexuality: these women reported significantly lower avoidance scores than those who only recovered from AN. Moderation analysis indicated that sexual desire did not increase in participants with higher levels of avoidant attachment.

Clinical implications: These novel findings highlighted the importance of the assessment of adult attachment in the clinical setting, for better characterization and treatment of persons suffering from AN.

Strengths & limitations: The long follow-up duration, the multidisciplinary nature of the treatment, and the novelty of the topic were major strengths of the study, whereas the limited sample size and the absence of biological data were the main limitations.

Conclusion: This study highlighted the crucial role of avoidant attachment in the relationship between AN and sexual dysfunctions, underlining the importance of integrating treatments with attachment-focused interventions. Cassioli E, Rossi E, Vizzotto C, et al. Avoidant Attachment Style Moderates the Recovery of Healthy Sexuality in Women With Anorexia Nervosa Treated With Enhanced Cognitive Behavior Therapy (CBT-E): A 2-Year Follow-Up Study. J Sex Med 2022;19:347-355.