Health Education and Health Promotion

Relationship Between Anxious Attachment, Family Health, and Addiction Susceptibility in University Students; the Mediating Role of Cognitive Emotion Regulation

Document Type : Descriptive & Survey

Authors

F. Rezaei
M. Talebzadeh Shoushtari
B. Makvandi
F.S. Marashian

Department of Psychology, Ahvaz Branch, Islamic Azad University, Ahvaz, Iran

https://doi.org/10.58209/hehp.11.3.399
Abstract
Aims: Individuals with substance use disorder often struggle with chronic and recurrent episodes, experiencing a lack of control over their behaviors and significant disruptions in motivation. This study investigated the relationship between anxious attachment, family well-being, and addiction susceptibility among university students with the mediating role of cognitive emotion regulation.

Instrument & Methods: This study utilized structural equation modeling, a widely recognized multivariate correlation method, to examine the relationship between various factors in the context of addiction susceptibility. The target population for this study comprised students from the Islamic Azad University of Ahvaz. Through convenience sampling, a sample of 300 students was selected. All participants completed the Potential Addiction Scale, Experience in Close Relationships Scale, Family-of-Origin Scale, and Cognitive Emotion Regulation Scale. The collected data underwent statistical analysis using SEM, revealing a well-fitted model.

Findings: Anxious attachment and family health significantly influenced participants' inclination toward addiction (p<0.001). These effects were directly and indirectly observed, mediated by cognitive emotion regulation (p<0.001).

Conclusion: Reducing addiction tendencies in young individuals can be achieved through training families and university students on cultivating secure attachment styles, employing adaptive cognitive regulation strategies, and promoting overall family health.

Keywords

Anxiety
Health
family
Addiction
Emotion
Students
Subjects
Introduction
Substance use disorder (SUD) represents a significant societal issue in the 21st century, with far-reaching complications that seriously threaten society [1]. This multidimensional psychiatric disorder involves maladaptive drug-use patterns and is closely associated with adverse consequences, including anxiety, depression, and diminished quality of life [2, 3]. Individuals with SUD often struggle with chronic and recurrent episodes, experiencing a lack of control over their behaviors and significant disruptions in motivation [4]. Numerous studies have underscored the pivotal role of anxious attachment in predisposing individuals to addiction [5, 6].
Attachment, which pertains to the emotional bond between a child and their primary caregiver, is crucial to seeking safety and security [7]. The development of attachment is influenced by familial, peer, and socio-emotional factors throughout adulthood, while attachment styles serve as transformative elements that shape personality traits and behavioral tendencies [8]. The attachment system functions as a behavioral adaptation mechanism that aims to alleviate tension and arousal resulting from fear, akin to the psychological counterpart of the immune system. Just as the immune system combats physical distress, the attachment system influences fundamental social interactions and psychological attributes [9]. Moreover, it significantly influences the development of personality disorders, emotional dysregulation, and antisocial behaviors [10]. An anxious attachment style often emerges due to inconsistent and negligent parental care during childhood [11].
Evidence suggests a significant relationship between family health and the propensity for addiction [12]. As an integral part of an individual's life, the family is a social and communication system. The health of the family reflects the proper functioning of its members. The experiences and dynamics within the family of origin play a pivotal role in the well-being of family members [13]. The term "family of origin" refers to an individual's interactions and experiences with their parents or caregivers during childhood, forming the foundation for their interpersonal relationships in adulthood [14]. Researchers have hypothesized about the profound influence of the family of origin on an individual's development [15]. According to cognitive theory, observing parental behavior shapes an individual's initial schemas for family life. The emotional connection between children and their parents within families is enduring, persisting over time and physical distance. Individuals are often emotionally attached to their family of origin, even after starting their own families [16]. Consequently, a positive relationship between children and parents in the family of origin can contribute to their overall satisfaction with their present life circumstances. However, experts suggest that intra-family relationships can also be a source of psychosocial problems for individuals [17].
Cognitive emotion regulation (CER) emerges as another noteworthy factor associated with addiction. Emotion regulation refers to the ability to understand, adjust, and express emotions, and it is a skill shaped by familial and social influences [18]. The emotion regulation process encompasses various stages of emotional processing, starting with accurate self-awareness and culminating in appropriately applying coping strategies to manage emotional arousal [19]. It is crucial to note that employing maladaptive emotion regulation methods can contribute to psychological and social difficulties during adolescence and adulthood [20]. The development of reasoning and representation skills and an individual's emphasis on emotion analysis and intervention significantly influence emotion regulation [21, 22]. This facet of regulation encompasses a range of skills aimed at recognizing, accepting, evaluating, adjusting, and transforming negative emotional states to navigate interpersonal and intrapersonal stressful situations [23] effectively. According to models of emotion regulation, adolescents who exhibit heightened emotional reactivity and encounter challenges in accepting, evaluating, and controlling their emotional responses are more likely to engage in self-harming behaviors [24].
According to the mentioned materials, the present study aimed to investigate the relationship between anxious attachment, family well-being, and addiction susceptibility among university students with the mediating role of cognitive emotion regulation.

Instrument and Methods
Design and participants
This correlational study employed structural equation modeling (SEM) as its analytical approach. The study population consisted of all students enrolled at the Islamic Azad University of Ahvaz in 2021. A total of 18 parameters were analyzed and calculated, which included 11 direct paths, two exogenous variables, one covariance, and error variances. To ensure the adequacy of the research sample for model testing, Kline [25] recommends a minimum of 15 participants for each parameter (18×15+50=320). Considering the possibility of receiving incomplete questionnaires, 320 questionnaires were distributed among the students. Finally, 300 students completed the questionnaires and entered the research process. With a sample size of 300, there were approximately 17 participants available for each parameter, indicating the sufficient size of the sample for testing the proposed model. The inclusion criteria for participant selection encompassed obtaining informed consent, being at least a sophomore, having no history of psychological disorders, not visiting a psychiatrist during the study period, and completing all the research questionnaires. Conversely, the exclusion criteria involved participants unwilling to continue participating in the study or providing incomplete questionnaires.
Instruments
Addiction Potential Scale (APS): The APS, developed by Weed et al. [26], comprises 41 items, including 36 regular items and five lie detectors. This scale assesses the propensity for addiction across two subscales: Active potential and passive potential. The first subscale primarily focuses on antisocial behaviors, drug cravings, positive attitudes toward drugs, and thrill-seeking tendencies. Meanwhile, the second subscale emphasizes self-expression difficulties and depressive symptoms. Participants rate each item on a 4-point Likert scale, ranging from 0 (Totally disagree) to 3 (Totally agree). Scores on the APS range from 0 to 180, with higher scores indicating a greater inclination toward addiction. Hosseinpour et al. [27] reported the reliability for this scale equal to 0.85.
Experience in Close Relationships (ECR) Scale: Developed by Brennan et al. [28], the ECR Scale is a self-report questionnaire comprising 36 items. It measures attachment insecurity through two categories: Attachment avoidance and attachment anxiety, with 18 items allocated to each category. The scale evaluates attachment across four subscales: Attachment to a mother, attachment to a father, attachment to friends, and attachment to a spouse. Participants rate each item on a 5-point Likert scale, ranging from 1 (Totally disagree) to 5 (Totally agree). Asgarizadeh et al. [29] reported the reliability for this scale equal to 0.83.
Family-of-Origin Scale (FOS): The FOS, developed by Hovestadt et al. [30], encompasses 40 items scored on a 5-point Likert scale, ranging from 1 (Totally disagree) to 5 (Totally agree). This scale evaluates the health of the family of origin along two dimensions: independence and intimacy. The total score on the FOS ranges from 40 to 200. Rajabi et al. [31] reported the reliability for this scale equal to 0.93.
Cognitive Emotion Regulation Scale (CERS): The CERS, developed by Garnefski et al. [32], consists of 36 items divided into nine subscales. Participants rate each item on a 5-point Likert scale, ranging from 1 (Totally disagree) to 5 (Totally agree). Five subscales of the CERS represent adaptive (Positive) cognitive emotion regulation strategies, including acceptance, positive refocusing, refocusing on planning, positive reappraisal, and putting things into perspective. The remaining four subscales represent maladaptive (Negative) emotion regulation strategies: self-blame, rumination, catastrophizing, and other blame. Badie et al. [33] reported the reliability for this scale equal to 0.88.
Data Analysis
The mean and standard deviation of research variables were used to evaluate descriptive data. In addition, Pearson's correlation coefficient was used to check the correlation between the studied variables. The goodness of fit of the proposed model was evaluated using various indices, including the Goodness of Fit Index (GFI), Adjusted Goodness of Fit Index (AGFI), Incremental Fit Index (IFI), Tucker-Lewis index (TLI), Comparative Fit Index (CFI), Normed Fit Index (NFI), and Root Mean Square Error of Approximation (RMSEA). The data obtained in this study were analyzed using SPSS-26 and AMOS-24 software.

Findings
The sample mean age was 21.33±2.61 years. There was a negative correlation between adaptive cognitive emotion regulation strategies and addiction susceptibility (r=-0.48) and a positive correlation between anxious attachment and maladaptive emotional regulation strategies (r=0.33; Table 1).

Table 1. Pearson correlation coefficient between parameters (all significant at p<0.01)


Anxious attachment and family health served as predictors, addiction susceptibility as the criterion, and cognitive emotion regulation as the mediating parameter. The proposed model (df=3) fitted well with the data (χ2=10.08; GFI=0.99; AGFI-0.92; IFI=0.9; TLI= 0.92; CFI=0.98; NFI=0.98; RMSEA=0.07).
Addiction susceptibility in the students had significant relationships with anxious attachment (β=0.23; p<0.001), family health (β=-0.22; p<0.001), adaptive cognitive emotion regulation strategies (β=-0.21; p<0.001), and maladaptive cognitive emotion regulation strategies (β=0.19; p<0.001; Table 2).

Table 2. Path coefficients of direct relationship between research parameters in the proposed model (all significant at p<0.001)


Adaptive and maladaptive cognitive emotion regulation strategies mediated the relationship between anxious attachment, family well-being, and addiction susceptibility among university students (p<0.001; Table 3).

Table 3. Path coefficients of indirect relationship between research parameters (all significant at p<0.001)


Discussion
The present study investigated the mediating role of cognitive emotion regulation in relationships between anxious attachment, family health, and addiction susceptibility among university students. The findings of this study indicate that anxious attachment and family health impacted the tendency of university students to develop an addiction, with cognitive emotion regulation mediating role. Consistent with previous research [34, 35], a positive and significant relationship was observed between anxious attachment and addiction tendencies. Several personality traits, including anxiety, depression, stress, and personality disorders, are known to increase the risk of drug addiction, and these traits are often prevalent among individuals with substance use disorders. Attachment plays a critical role in establishing a sense of security within relationships throughout life, and early relationships serve as templates for future social interactions [34]. Responsive and nurturing care provides a secure base, offering comfort, support, and protection, and helps individuals develop positive self-perceptions and perceptions of others. On the other hand, inadequate care is associated with anxiety, anger, dependency, and the suppression of needs. Early attachment relationships shape internal patterns that contain information about oneself, others, and relationship dynamics, influencing behavior and personality traits over the lifespan. Individuals with an anxious attachment style exhibit a compulsive desire for closeness, heightened sensitivity to rejection and abandonment cues, negative self-perceptions, and positive perceptions of others [6]. Difficulties in interpersonal relationships and a lack of empowerment can lead individuals with an anxious attachment style to seek relief through substance abuse.
The study results also revealed a positive and significant association between family-of-origin health and addiction tendency, consistent with previous research [3]. This finding can be explained by the fact that families that promote independence and forgiveness for minor mistakes enhance their children's abilities and self-esteem. These families also encourage self-direction by entrusting responsibilities to their children [12]. Moreover, due to close family relationships, children feel comfortable bringing their problems to the family and seeking the guidance and opinions of family members to correct their mistakes. Therefore, the family acts as a protective factor against external threats such as addiction [16].
The results of this study provide evidence for the significant impact of adaptive strategies of cognitive emotion regulation on the tendency toward addiction, which is consistent with previous research findings [36]. For example, Abolghasami et al. [36] demonstrated the significant influence of emotion regulation strategies on individuals with substance abuse problems. Adaptive strategies of cognitive emotion regulation include acceptance, focus, positive refocusing, refocusing on planning, positive reappraisal, and undermining. Research has shown that individuals who regularly employ cognitive reappraisal to regulate their emotions in daily life demonstrate greater resilience to stress [23]. Cognitive reappraisal is an adaptive strategy that helps individuals modify their emotional responses to stressful events, enhancing their performance and reducing the likelihood of drug abuse.
Additionally, the study findings revealed a positive and significant association between maladaptive emotion regulation strategies and the tendency towards addiction, which aligns with the results of Abolghasami et al. [36], who found a significant relationship between negative emotion regulation strategies and interpersonal behaviors among individuals with substance abuse disorders. Models of substance use disorder (SUD) suggest that individuals who struggle to regulate their emotions effectively may turn to drug abuse as a coping mechanism. Treatment approaches for SUD discourage using maladaptive emotion regulation strategies and promote the adoption of adaptive strategies. Individuals with difficulty controlling their impulses are at a higher risk of developing drug or alcohol addiction. Addicts with heightened emotional reactivity tend to employ maladaptive emotion regulation strategies, while those with lower reactivity utilize adaptive strategies. Increased reactivity and maladaptive negative emotion regulation strategies appear to be risk factors for drug abuse [36].
However, it is important to acknowledge certain limitations of this study. Firstly, the research was conducted exclusively on students from the Islamic Azad University of Ahvaz, and caution should be exercised when generalizing the results to other populations. Therefore, future studies should investigate diverse populations encompassing different age groups and educational attainment levels.

Conclusion
Cognitive emotion regulation mediates the relationship between anxious attachment, family health, and the tendency toward addiction.

Acknowledgments: This article was extracted from a part of the PhD dissertation of Mrs. Fahimeh Rezaei in the Islamic Azad University, Ahvaz, Iran. The authors would like to appreciate the collaboration of all participants in the present study.
Ethical Permissions: The Ethical Committee of the Islamic Azad University of Ahvaz approved the study (IR.IAU.AHVAZ.REC.1400.039).
Conflicts of Interests: There are no conflicts of interest regarding the publication of the current research.
Authors’ Contribution: Fahimeh Rezaei F (First Author), Introduction Writer/Main Researcher (25%); Talebzadeh Shoushtari M (Second Author), Introduction Writer/Methodologist/Main Researcher/Discussion Writer (35%); Makvandi B (Third Author), Methodologist/Discussion Writer (20%); Marashian FS (Fourth Author), Assistant Researcher/Statistical Analyst (20%)
Funding/Support: This is a self-funding study.
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  2. Connery HS, McHugh RK, Reilly M, Shin S, Greenfield SF. Substance use disorders in global mental health delivery: Epidemiology, treatment gap, and implementation of evidence-based treatments. Harv Rev Psychiatry. 2020;28(5):316-27. [Link] [DOI:10.1097/HRP.0000000000000271]
  3. Spencer AE, Valentine SE, Sikov J, Yule AM, Hsu H, Hallett E, et al. Principles of care for young adults with co-occurring psychiatric and substance use disorders. Pediatrics. 2021;147(Suppl 2):229-39. [Link] [DOI:10.1542/peds.2020-023523F]
  4. Ritanti R, Permatasari I, Nurdiantami Y. The relationship of resilience and family functioning with substance abuse risk behavior among adolescents. Health Educ Health Promot. 2023;11(2):1-6. [Link]
  5. Wojciechowski TW. Early life poly-victimization and differential development of anxiety as risk factors for the continuity of substance dependence in adulthood. Subst Use Misuse. 2020;55(8):1347-55. [Link] [DOI:10.1080/10826084.2020.1741637]
  6. Feizollahi Z, Asadzadeh H, Mousavi SR. Prediction of symptoms of psychosomatic disorders in university students based on perfectionism mediated by smartphone addiction. Cas J Health Res. 2022;7(3):151-8. [Link] [DOI:10.32598/CJHR.7.3.421.1.7]
  7. Schindler A. Attachment and substance use disorders-theoretical models, empirical evidence, and implications for treatment. Front Psychiatry. 2019;10:727. [Link] [DOI:10.3389/fpsyt.2019.00727]
  8. Benoit D. Infant-parent attachment: Definition, types, antecedents, measurement and outcome. Paediatr Child Health. 2004;9(8):541-5. [Link] [DOI:10.1093/pch/9.8.541]
  9. Rübig LL, Fuchshuber J, Köldorfer P, Rinner A, Fink A, Unterrainer HF. Attachment and therapeutic alliance in substance use disorders: Initial findings for treatment in the therapeutic community. Front Psychiatry. 2021;12:730876. [Link] [DOI:10.3389/fpsyt.2021.730876]
  10. Asadollahi T, Miri M R, Norozi E, Hosseini T, Sharifzade G. An enquiry into the predictive power of the theory of planned behavior for attachment styles of housewives. Health Educ Health Promot. 2017;5(1):19-29. [Link]
  11. Turner M, Beckwith H, Duschinsky R, Forslund T, Foster SL, Coughlan B, Pal S, Schuengel C. Attachment difficulties and disorders. InnovAiT. 2019;12(4):173. [Link] [DOI:10.1177/1755738018823817]
  12. Eftekhari A, Bakhtiari M, Kianimoghadam AS. The relationship between the attachment styles of children, parenting styles, and the socio-economic status of parents. J Communit Health Res. 2022;11(4):249-55. [Link] [DOI:10.18502/jchr.v11i4.11640]
  13. Zeng X, Tan C. The relationship between the family functioning of individuals with drug addiction and relapse tendency: A moderated mediation model. Int J Environ Res Public Health. 2021;18(2):625. [Link] [DOI:10.3390/ijerph18020625]
  14. Kumpfer KL. Family-based interventions for the prevention of substance abuse and other impulse control disorders in girls. ISRN Addict. 2014;2014:308789. [Link] [DOI:10.1155/2014/308789]
  15. Srivastava S, Kumar P, Rashmi, Paul R, Dhillon P. Does substance use by family members and community affect the substance use among adolescent boys? Evidence from UDAYA study, India. BMC Public Health. 2021;21(1):1896. [Link] [DOI:10.1186/s12889-021-11911-5]
  16. Horigian VE, Anderson AR, Szapocznik J. Family-based treatments for adolescent substance use. Child Adolesc Psychiatr Clin N Am. 2016;25(4):603-28. [Link] [DOI:10.1016/j.chc.2016.06.001]
  17. Zeng X, Lu M, Chen M. The relationship between family intimacy and relapse tendency among people who use drugs: A moderated mediation model. Subst Abuse Treat Prev Policy. 2021;16(1):48. [Link] [DOI:10.1186/s13011-021-00386-7]
  18. Saladino V, Mosca O, Petruccelli F, Hoelzlhammer L, Lauriola M, Verrastro V, et al. The vicious cycle: Problematic family relations, substance abuse, and crime in adolescence: A narrative review. Front Psychol. 2021;12:673954. [Link] [DOI:10.3389/fpsyg.2021.673954]
  19. Roohi S, Noroozi H, Yousefi Afrashteh M. Mediating role of resilience and self-efficacy in the relationship between cognitive emotion regulation strategies and psychological well-being of iranian students. Health Educ Health Promot. 2019;7(4):183-90. [Link]
  20. Asadi SS, Bakhshipour Roudsari A, Mahmoud Alilou M, Seyed Mousavi PS. The relationship between attachment security and emotional dysregulation of adolescent: The mediating role of mentalization ability. Frooyesh. 2022;10(12):85-96. [Persian] [Link]
  21. Khodabakhsh MR, Maghmoumi V, Kiani F. Do depression symptoms predict eating disturbance? the role of emotion regulation strategy as a mediator. Health Educ Health Promot. 2015;3(1):25-32. [Link]
  22. Weiss NH, Kiefer R, Goncharenko S, Raudales AM, Forkus SR, Schick MR, et al. Emotion regulation and substance use: A meta-analysis. Drug Alcohol Depend. 2022;230:109131. [Link] [DOI:10.1016/j.drugalcdep.2021.109131]
  23. Stellern J, Xiao KB, Grennell E, Sanches M, Gowin JL, Sloan ME. Emotion regulation in substance use disorders: A systematic review and meta-analysis. Addiction. 2023;118(1):30-47. [Link] [DOI:10.1111/add.16001]
  24. Shahbazirad A, Azizi M. Effectiveness of teaching emotion regulation strategies in improving cognitive-emotional regulation among female students in addiction-stricken areas of Kermanshah city. J Family Reprod Health. 2018;12(4):204-9. [Link]
  25. Garke MÅ, Isacsson NH, Sörman K, Bjureberg J, Hellner C, Gratz KL, et al. Emotion dysregulation across levels of substance use. Psychiatry Res. 2021;296:113662. [Link] [DOI:10.1016/j.psychres.2020.113662]
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Health Education and Health Promotion
Volume 11, Issue 3
Autumn 2023
Pages 399-404