Attachment style and premenstrual symptom severity: the mediating role of maladaptive emotion regulation

ABSTRACT

Objective

The present study examined the relationship between attachment and premenstrual symptoms, and the mediating role of maladaptive emotion regulation.

Method

Attachment orientation, maladaptive emotion regulation, and premenstrual symptom severity were measured using a cross-sectional design among female university students who were naturally cycling (n = 165) or currently using hormonal contraception (HC) (n = 124).

Results

Partial correlations, controlling for age, cycle regularity, and general symptoms of psychopathology (depression, anxiety, and stress), revealed positive associations between maladaptive emotion regulation and premenstrual symptoms, and between anxious attachment and maladaptive emotion regulation for both groups of women. Moreover, among women who were naturally cycling, maladaptive emotion regulation positively mediated the relationship between anxious (but not avoidant) attachment and premenstrual symptom severity; anxious attachment was associated with more severe premenstrual symptoms via increased maladaptive emotion regulation. This same mediation pathway was not observed for participants currently using HC.

Conclusions

The findings highlight that a negative model of the self, which is characteristic of an anxious attachment style, may be a useful psychotherapeutic target for naturally cycling women who experience premenstrual symptoms. Further research and replication are required to confirm the potential moderating effect of HC and hormonal changes on these relationships.

Key Points

What is already known about this topic:

1. Premenstrual symptoms affect approximately 70–90% of reproductive-age women.

2. Elevated premenstrual symptoms are associated with adverse psychological outcomes including lower health-related quality of life and increased risk of suicide.

3. Maladaptive emotion regulation has been implicated in heightened premenstrual symptom severity; however, the role of attachment style has been underexplored.

What this topic adds:

1. Anxious attachment was associated with elevated premenstrual symptoms via maladaptive emotion regulation among women who were naturally cycling.

2. A negative model of the self may be the theoretical mechanism underlying the link between anxious attachment and premenstrual symptoms.

3. Psychotherapies that address underlying attachment insecurity may improve emotion regulation and, thus, reduce premenstrual symptom severity.

KEYWORDS:

• Anxious attachment
• avoidant attachment
• emotion regulation
• menstruation
• women’s health

Introduction

Premenstrual symptoms are highly prevalent and can have a profound and debilitating impact upon the lives of women. Approximately 70–90% of reproductive-age women experience some form of premenstrual symptomatology (Braverman, 2007). These symptoms are experienced on a continuum of severity; 40–60% of symptomatic women are classified as having moderate symptoms (in the form of Premenstrual Syndrome; PMS), and 3–8% experience these symptoms at severe levels, thus meeting criteria for a diagnosis of Premenstrual Dysphoric Disorder (PMDD) (Ryu & Kim, 2015). Premenstrual symptoms are associated with lower health-related quality of life, relationship difficulties, increased risk of perimenopausal and postpartum depression, disrupted work and academic performance, and an elevated risk of suicide (Cunningham et al., 2009; Karimiankakolaki et al., 2019). Given the adverse nature of these consequences, it is important to understand the factors implicated in the development of premenstrual symptoms.

Premenstrual symptoms span affective (depressed mood, anxiety, anger, affective lability), somatic (breast tenderness, bloating, headache, fatigue), and behavioural (social withdrawal, restlessness) domains (Padmavathi et al., 2014). There are individual differences in the constellation of premenstrual symptoms experienced by women. However, those with an affective component can be considered the most burdensome (Schmelzer et al., 2015). Although the precise aetiology remains unclear, a sensitivity to hormonal cyclical variations (Dilbaz & Aksan, 2021), elevated pain perception (Fillingim et al., 1995; Ozgocer et al., 2017), as well as the role of neurotransmitters serotonin and GABA (Nevatte et al., 2013), have been implicated in the occurrence of heightened premenstrual symptomatology. However, the aforementioned factors alone do not offer a complete explanation for why some women experience elevated premenstrual symptoms and, therefore, psychological mechanisms require further exploration.

There is some evidence to suggest that women’s increased experience of negative affect during the premenstrual period may be partly explained by maladaptive emotion regulation or using less effective and less flexible approaches to process, respond to, and manage emotions (Eggert et al., 2016; Petersen et al., 2016). Maladaptive emotion regulation typically occurs via the use of strategies such as rumination and suppression, which have been positively associated with psychological distress and emotional problems, diminished perceptions of social support, and heightened risk of psychopathology (Garnefski & Kraaij, 2007; Gürdal et al., 2018). Importantly, women with PMDD have been found to be more likely to experience difficulties in regulating their emotions than those without PMDD (Petersen et al., 2016). Meers et al. (2020) also found that maladaptive emotion regulation mediated the relationship between depressive and premenstrual symptoms; negative mood was associated with an increased inability to regulate emotions, and thus, a heightened perception of premenstrual somatic and mood symptoms. Moreover, women with PMS have been found to be more likely to employ less helpful emotion regulation strategies (i.e., self-blame, rumination and catastrophising), compared to those without PMS (Eggert et al., 2016).

Given that emotion regulation skills are influenced by attachment patterns forged during childhood (Mikulincer & Shaver, 2016), it is important to elucidate the role that attachment may play in women’s experience of premenstrual symptom severity. The attachment relationship between a child and their primary caregiver(s) can shape an individual’s ability to regulate their emotions through the development of internal representations which reflect caregiver responses to the child’s emotional needs (Mikulincer & Shaver, 2016). Attachment figures who are attentive, reassuring, and responsive, cultivate a secure attachment, whereby the individual develops a positive representation of the self as worthy of care, and the belief that others are willing and able to provide support when required (Mikulincer & Shaver, 2008). In contexts where the formation of attachment security is tarnished, such as when caregivers are inconsistent, harsh, rejecting, absent, or unresponsive, insecure attachment patterns can arise (Mikulincer & Shaver, 2016).

Insecure patterns of attachment are conceptualised as existing along the two dimensions of attachment anxiety and attachment avoidance (Fraley et al., 2000). Specifically, negative models of the self are argued to contribute to attachment anxiety, and negative models of others can elicit attachment avoidance (Malik et al., 2014). Those with higher levels of attachment anxiety typically maintain that they are unworthy of care and, consequently, harbour concern regarding the availability and responsiveness of others (Mikulincer & Shaver, 2012). Further to this, anxiously attached individuals experience elevated vigilance to abandonment and rejection, have diminished confidence in their own ability to cope, and engage in increased reassurance-seeking behaviours (Fraley et al., 2000; Mikulincer & Shaver, 2016). Such responses have typically developed as a means of coping with caregivers who have been inconsistently available and contribute to the development of a negative self-concept (Mikulincer & Shaver, 2016). Individuals with higher levels of attachment-related avoidance are more likely to display distrust in the intentions of others and tend to cope with hardship and vulnerability by relying on themselves and seeking distance from others (Fraley et al., 2000; Mikulincer & Shaver, 2016). The behaviours that characterise attachment avoidance are reported to emerge as strategies for coping with caregivers who were abusive, harsh, critical, or rejecting, which has, thus, contributed to the development of a negative view of others (Mikulincer & Shaver, 2016). Individuals with low attachment anxiety and low attachment avoidance are classified as securely attached (Fraley et al., 2000).

Approaches to emotion regulation vary significantly across the secure, anxious, and avoidant patterns of attachment. Securely attached individuals are more likely to regulate their emotions using strategies such as problem-solving and support-seeking, and overall, demonstrate more adaptive emotion regulation (Gardner et al., 2020). By contrast, individuals with high attachment anxiety are more likely to employ hyperactivating strategies such as engaging in the use of clinging, controlling and coercive behaviours, to seek proximity to, and elicit support from, caregivers who are otherwise unavailable (Mikulincer & Shaver, 2012, 2016). Those with high attachment avoidance tend to utilise deactivating strategies including withdrawal from relationships and an emphasis on self-reliance to protect themselves from caregiver rejection (Mikulincer & Shaver, 2016). Indeed, research by Snyder et al. (2023) revealed a positive association between maladaptive emotion regulation and insecure (i.e., anxious and avoidant) attachment. Additionally, emotion regulation difficulties were found to mediate the relationship between adverse childhood experiences and insecure attachment. Moreover, Maunder and Hunter (2001) have argued that attachment insecurity is associated with heightened risk of stress and disease via its effects on exacerbated physiological stress responses, reduced internal affect regulation, and a heightened reliance on external (i.e., substance use) rather than internal sources of emotion regulation.

In summary, individuals with higher levels of attachment anxiety or attachment avoidance have a proclivity to deploy less adaptive emotion regulation strategies as they have not learned more effective means of obtaining support or have been consistently unsuccessful in their attempts (Mikulincer & Shaver, 2016). Consequently, insecurely attached individuals can rely more upon maladaptive emotion regulation and experience heightened rates of emotional problems and associated psychopathology (Pascuzzo et al., 2015; Pepping et al., 2013). Given the link between attachment and emotion regulation, it is therefore unsurprising that insecure attachment styles have been associated with heightened levels of distress, reduced well-being, difficulties in coping with stress, and an increased risk of psychiatric illness (Mikulincer & Shaver, 2016).

The current study

The psychological correlates of insecure patterns of attachment, specifically their association with maladaptive emotion regulation, indicate that insecure attachment may exacerbate premenstrual symptomatology via its effect on maladaptive emotion regulation. Presently, however, no research has investigated this possibility and the current study was designed to address this gap.

Importantly, there is limited and mixed evidence regarding the effect of hormonal contraception (HC) on the menstrual cycle (Rivera et al., 1999), self-reported psychological phenomena (Blake et al., 2022; Fruzzetti & Fidecicchi, 2020; Martell et al., 2023), and the severity of premenstrual symptoms (Yonkers et al., 2017). Because HC operates via changes to ovulation and hormone (i.e., oestrogen and progesterone) levels which may influence the experience of premenstrual symptoms (Blake et al., 2022; Rivera et al., 1999), we have provided separate results for women who were currently using HC and those who were not (i.e., women who were naturally cycling). In addition, age has been shown to be positively associated with premenstrual symptom severity in some studies (Hantsoo et al., 2022). Thus, in our investigation, we also included statistical controls for age, cycle regularity, and current general (i.e., non-menstruation specific) symptoms of depression, anxiety, and stress. With these covariates, it was hypothesised that attachment anxiety and attachment avoidance would be positively associated with both premenstrual symptom severity and maladaptive emotion regulation. It was further predicted that maladaptive emotion regulation would be positively associated with premenstrual symptom severity and that it would positively mediate the relationship between attachment insecurity and premenstrual symptom severity. As we are not aware of evidence linking attachment style with the use of HC, and because cyclical premenstrual symptom change has been observed in both HC and naturally cycling women (Yonkers et al., 2017), we anticipated that the same patterns would be observed for all participants regardless of HC status.

Materials and methods

Participants

Participants were 289 female undergraduate students ranging in age from 16 to 48 years (M = 21.51, SD = 5.50) recruited via an online research participation system in exchange for partial course credit. To be included in the study, participants needed to identify with the female gender and experience menstruation. Participants were not eligible to participate if they were pregnant or had a current diagnosis of a mental health condition, polycystic ovarian syndrome, and/or endometriosis. Participants were primarily Caucasian (n = 226, 78.2%) or Asian/Pacific islander (n = 25, 8.7%). Fewer than 5% of women identified as “other” racial (n = 13, 4.5%), or were Indigenous or Aboriginal (n = 9, 3.1%), Multiracial (n = 8, 2.8%), African-American (n = 3, 1.0%), Latino (n = 3, 1.0%), or preferred not to specify (n = 2, 0.7%). Most women were single (n = 127, 43.9%), in a relationship (n = 112, 38.8%), or living with a partner (n = 36, 12.5%). Most participants completed year 12 (n = 186, 64.4%), an advanced diploma/diploma (n = 33, 11.4%), or a certificate III/IV (n = 32, 11.1%) as their highest level of education. Many participants engaged in part-time/casual employment (n = 160, 55.4%), full-time study (n = 88, 30.4%), or full-time employment (n = 22, 7.6%).

All participants indicated that they experienced cyclical bleeding and most (85.8%) classified their menstrual pattern as usually or always regular with fewer (14.2%) reporting an irregular pattern. Almost half of the sample reported currently using HC (42.9%); there was no difference in the self-reported regularity of the menstrual cycle between those participants who were currently using HC and those who were naturally cycling, χ2 (1, N = 289) = 0.02, p = .89. Independent-samples t-tests revealed that women using HC were younger (M = 20.62, SD = 4.37) than women naturally cycling (M = 22.17, SD = 6.15), t(287) = −2.39, p = .013, d = −0.28, and women using HC also reported lower avoidant attachment (M = 2.75, SD = 1.22) than naturally cycling women (M = 3.07, SD = 1.14), t(287) = −2.27, p = .024, d = −0.27. However, both effects were small, and these two groups of women did not differ on depression, anxiety, stress, anxious attachment, maladaptive emotion regulation, or premenstrual symptoms (all p’s > .05). There were also no group differences on any of these variables between women who reported regular or irregular cycle (all p’s > .05). Participants reported that they were aged between 9 and 18 years when they first began menstruating (M = 12.81, SD = 1.54).

Measures

Depression, anxiety and stress

The 21-item Depression Anxiety and Stress Scale (DASS-21) was used to measure depression, anxiety, and stress. Participants rated their responses on a 4-point Likert scale, ranging from 0 (never) to 3 (almost always), based on how much the symptoms were experienced over the past week. Each subscale comprised 7-items, with higher summed scores indicating elevated levels of depression, anxiety, and stress symptoms. The three subscales of the DASS-21 have been reported to have excellent reliability and validity (Coker et al., 2018). Cronbach’s alpha revealed that internal consistency in the current sample was high (depression: α = .89; anxiety: α = .87; stress: α = .86).

Premenstrual symptoms

The Premenstrual Syndrome Scale (PMSS; Padmavathi et al., 2014) is a 40-item measure assessing physiological (e.g., “headache”, “fatigue”), psychological (e.g., “mood swings”, “hopelessness”) and behavioural premenstrual symptoms (e.g., “social withdrawal”, “lack of interest in usual activities”). The PMSS used retrospective self-report; participants were asked to report “the intensity of your premenstrual symptoms during your last cycle. The premenstrual phase of your cycle begins about seven days before your period and ends about the time bleeding starts”. Participants rated items on a 5-point Likert scale from 1 (never) to 5 (always), with the total summed score ranging from 40 to 200 (higher scores reflected greater premenstrual symptom severity). In previous research, the PMSS has been reported to have an inter-rater reliability of between .81 and .97, with sensitivity and specificity scores ranging from 83–100% and 64–90%, respectively (Padmavathi et al., 2014). Excellent internal consistency was calculated for the PMSS in the current study (α = .96).

Maladaptive emotion regulation

Four subscales of the 36-item Cognitive Emotion Regulation Questionnaire, known to be less helpful and positively correlated with heightened emotional problems (CERQ; Garnefski & Kraaij, 2007), were used to measure maladaptive emotion regulation: self-blame, rumination, catastrophising, and blaming others. Participants rated each item on a 5-point Likert scale ranging from 1 (almost never) to 5 (almost always). Subscale scores were summed to create a total where higher values indicated a greater tendency to utilise maladaptive emotion regulation strategies. Good reliability and sound validity have been reported for the CERQ (Garnefski & Kraaij, 2007). Internal consistency was high for the combined maladaptive emotion regulation categories (α = .86), as measured in the current sample.

Attachment

The Experiences in Close Relationships – Revised (ECR-R) is a 36-item measure comprising two 18-item subscales: attachment anxiety (e.g., “I worry a lot about my relationships”) and attachment avoidance (e.g., “I prefer not to show a partner how I really feel deep down”). Participants were asked to rate their responses to each item on a 7-point Likert scale from 1 (strongly disagree) to 7 (strongly agree). Scores for each subscale were summed, with higher scores demonstrating a stronger endorsement of a particular attachment style. Good reliability and validity have been reported for the two ECR-R subscales in previous research (Sibley et al., 2005). In the current study, internal consistency for each of the subscales was high (anxious: α = .93; avoidant: α = .94).

Procedure

Ethics approval was received from the Griffith University HREC (GU Ref No: 2020/601) before commencing data collection via an online survey. In accord with the university’s HREC statement, university student participants are primary consenting agents; participants under 18 years of age were considered able to make an informed decision regarding their own participation in the study. Participants were provided with an information sheet overviewing the research and consent was implied through the completion of the demographic questions, DASS-21, PMSS, CERQ and ECR-R. Except for the demographic questions which always came first, questionnaires were presented in a counterbalanced order.

Statistical analysis

Analyses were conducted using IBM SPSS Version 26.0. Assumptions of mediated regression were assessed, which revealed that age and general levels of depression and anxiety were positively skewed. Square root transformation improved the skew. However, the main results did not differ using the transformed variables, thus the original raw data were used in the main analyses to aid interpretability. Four univariate outliers (for age) and one multivariate outlier were detected. However, responses were within valid ranges and removing these cases also did not change the results, so all participants have been included in the analyses (Cousineau & Chartier, 2010). There was no missing data, and all other assumptions were met.

As indicated by Fritz and MacKinnon (2007), a sample size of 71 is sufficient to detect a bias-corrected bootstrapped indirect effect, with medium-sized “a” and “b” paths and 80% statistical power. To test the main hypotheses, for each of the sub-samples of participants (naturally cycling, n = 165; HC, n = 124), partial correlations were conducted exploring the relationships between key variables, controlling for age, cycle regularity, and general symptoms of depression, anxiety, and stress. Using the same covariates, Model 4 of the SPSS extension PROCESS macro (Hayes, 2022) was utilised to run two mediation analyses (one with anxious attachment as a predictor and one with avoidant attachment as a predictor) for each of the sub-samples separately (i.e., four mediation analyses all together) testing whether maladaptive emotion regulation mediated the attachment style-premenstrual symptom relationship. The PROCESS macro employed the use of ordinary least squares regression analyses in addition to bootstrapping procedures to test for indirect effects (Preacher & Hayes, 2008). A bootstrap sample of n = 5000 was used, and 95% bias-corrected bootstrap confidence intervals were examined to determine whether scores significantly differed from zero. Indirect effects that did not contain zero in the 95% confidence interval were deemed to provide evidence of a mediation effect.

Results

Descriptive statistics and partial correlations for key variables

As reported in Table 1, for both sub-samples of participants, there were significant positive partial correlations between maladaptive emotion regulation and premenstrual symptoms. Moreover, anxious attachment was positively associated with maladaptive emotion regulation. There were no correlations between any attachment style and premenstrual symptoms.

Table 1. Descriptive statistics and partial correlations for key variables.

	Naturally Cycling n = 165				Using Hormonal Contraception n = 124
	M(SD)	1	2	3	M(SD)	1	2	3
1. Anxious attachment	3.43(1.20)	–			3.44(1.38)	–
2. Avoidant attachment	3.07(1.14)	.24*	–		2.75(1.22)	.26*	–
3. Maladaptive emotion regulation	45.12(10.00)	.19*	.04	–	47.36(9.36)	.20*	−.07	–
4. Premenstrual symptoms	112.45(33.24)	.06	−.05	.26*	115.58(29.32)	.11	−.00	.20*

*p < .05.

Attachment as a mediator of the maladaptive emotion regulation-premenstrual symptoms relationship

Anxious attachment

For both sub-samples of participants, anxious attachment was positively associated with maladaptive emotion regulation (path “a”). Furthermore, path “b” revealed a positive association between maladaptive emotion regulation and premenstrual symptoms. Path model “c”’ indicated that anxious attachment was not directly associated with premenstrual symptoms. For naturally cycling women, the indirect effect revealed evidence of mediation whereby anxious attachment positively predicted premenstrual symptoms via maladaptive emotion regulation, F(7, 157) = 24.13, R² = .5183, p < .001, 96% CI for indirect effect [0.07, 2.71]. Figure 1 displays the mediation pathways for anxious attachment among the naturally cycling women. However, for participants currently using HC, there was no evidence of mediation, F(7, 116) = 16.39, R² = .4973, p < .001, 95% CI for the indirect effect [−0.05, 1.95]. Path model coefficients for these analyses are presented in Table 2.

Figure 1. Mediation pathways for anxious attachment (controlling for age, cycle regularity, depression, anxiety, and stress) among naturally cycling women (n = 165).

Table 2. Mediation results for anxious attachment.

	Naturally Cycling n = 165		Using Hormonal Contraception n = 124
	B(SE)	95% CI	B(SE)	95% CI
Path “a”
Age	0.11(0.12)	[−0.13,0.36]	0.19(0.17)	[−0.14,0.52]
Cycle regularity	−1.19(2.04)	[−5.21,2.84]	−3.30(2.03)	[−7.32,0.72]
Depression	0.57(0.24)*	[0.10,1.04]	0.41(0.22)	[−0.03,0.86]
Anxiety	0.01(0.25)	[−0.49,0.51]	0.32(0.25)	[- 0.18,0.82]
Stress	0.37(0.24)	[−0.09,0.84]	0.20(0.26)	[−0.32,0.71]
Anxious attachment	1.62(0.65)*	[0.33,2.90]	1.29(0.59)*	[0.13,2.45]
Path “b”, “c’”
Age	0.24(0.33)	[−0.42,0.90]	−0.32(0.46)	[−1.23,0.59]
Cycle regularity	3.77(5.46)	[−7.03,14.56]	4.92(5.66)	[−6.29,16.13]
Depression	0.84(0.65)	[−0.45,2.13]	0.54(0.62)	[−0.69,1.77]
Anxiety	0.29(0.68)	[−1.06,1.63]	0.77(0.70)	[−0.63,2.17]
Stress	3.58(0.64)*	[2.31,4.85]	2.26(0.72)*	[0.83,3.69]
Anxious attachment	0.21(1.78)	[−3.29,3.72]	1.23(1.65)	[−2.03,4.49]
Maladaptive emotion regulation	0.70(0.21)*	[0.28,1.13]	0.52(0.25)*	[0.02,1.03]

*p < .05.

Avoidant attachment

For both sub-samples of participants, avoidant attachment was not associated with maladaptive emotion regulation (path “a”). By contrast, path “b” revealed that maladaptive emotion regulation was positively associated with premenstrual symptoms. As evidenced in path “c”’, avoidant attachment was not associated with premenstrual symptoms. Path model coefficients for these analyses can be seen in Table 3. There was no evidence of mediation for participants who were naturally cycling, F(7, 157) = 24.32, R² = .5202, p < .001, 95% CI for the indirect effect [−0.77, 1.56], or for participants currently using HC, F(7, 116) = 16.24, R² = .4949, p < .001, 95% CI for the indirect effect [−1.35, 0.41].

Table 3. Mediation results for avoidant attachment.

	Naturally Cycling n = 165		Using Hormonal Contraception n = 124
	B(SE)	95% CI	B(SE)	95% CI
Path “a”
Age	0.22(0.17)	[−0.12,0.56]	0.09(0.13)	[−0.16,0.34]
Cycle regularity	−2.91(2.06)	[−7.00,1.17]	−2.04(2.07)	[−6.13,2.05]
Depression	0.48(0.23)*	[0.03,0.93]	0.71(0.24)*	[0.25,1.18]
Anxiety	0.46(0.26)	[−0.05,0.97]	−0.01(0.26)	[−0.53,0.51]
Stress	0.23(0.27)	[−0.30,0.76]	0.41(0.24)	[−0.08,0.89]
Avoidant attachment	−0.47(0.63)	[−1.72,0.88]	0.34(0.67)	[−0.97,1.66]
Path “b”, “c’”
Age	−0.34(0.47)	[−1.27,0.59]	0.19(0.34)	[−0.48,0.85]
Cycle regularity	5.57(5.64)	[−5.59,16.74]	4.27(5.46)	[−6.51,15.05]
Depression	0.55(0.63)	[−0.69,1.80]	0.88(0.64)	[−0.38,2.14]
Anxiety	0.83(0.71)	[−0.58,2.24]	0.40(0.69)	[−0.97,1.77]
Stress	2.31(0.73)*	[0.87,3.74]	3.50(0.65)*	[2.22,4.78]
Avoidant attachment	0.23(1.71)	[−3.17,3.62]	−1.41(1.75)	[−4.87,2.05]
Maladaptive emotion regulation	0.56(0.25)*	[0.07,1.06]	0.72(0.21)*	[0.30,1.13]

*p < .05.

Discussion

The present study investigated whether patterns of attachment were associated with women’s experience of premenstrual symptom severity, and whether maladaptive emotion regulation mediated these relationships. We also explored these mediation pathways for sub-groups of participants who were naturally cycling and those who were currently using HC. Regardless of current use of HC, no direct association was evident between the anxious or avoidant patterns of attachment and premenstrual symptom severity. For all women, attachment anxiety (but not attachment avoidance) was positively associated with maladaptive emotion regulation. Further, a consistent but small pattern of positive association was identified between maladaptive emotion regulation and premenstrual symptom severity. Finally, in partial support of our hypotheses, maladaptive emotion regulation mediated the relationship between attachment anxiety (but not attachment avoidance) and premenstrual symptom severity for the sub-group of naturally cycling women. For women currently using HC, there was no evidence of mediation.

The positive association between attachment anxiety and maladaptive emotion regulation is consistent with Maunder and Hunter’s (2001) model linking attachment insecurity with poorer internal affect regulation and heightened risk of disease. The finding also echoes research by Pascuzzo et al. (2015), whereby the results were interpreted to reflect the use of hyperactivating and emotion-focused strategies (i.e., self-blame, self-criticism, rumination) in those with higher levels of attachment anxiety. Given that individuals with high attachment anxiety tend to experience amplified negative emotions, have increased accessibility to adverse memories, and find it challenging to placate negative feelings (Mikulincer & Shaver, 2012), it follows that these individuals may also rely upon maladaptive emotion regulation (Mikulincer & Shaver, 2016; Pascuzzo et al., 2015; Snyder et al., 2023). The finding that maladaptive emotion regulation was positively associated with women’s premenstrual symptom severity also supports previous research reporting elevated maladaptive emotion regulation among women with PMS (Eggert et al., 2016) and PMDD (Petersen et al., 2016).

The current findings extend our knowledge in several pivotal ways. Although a pathway between attachment insecurity and the development of psychopathology (as mediated by maladaptive emotion regulation) has previously been established (Cronin et al., 2018; Pascuzzo et al., 2015), this is the first study to explore the relationships between specific attachment patterns, maladaptive emotion regulation and women’s experience of premenstrual symptoms. We also explored the moderating role of HC in these relationships. In line with predictions, for women who were naturally cycling, maladaptive emotion regulation mediated the positive association between attachment anxiety and premenstrual symptom severity while controlling for age, cycle regularity, and general symptoms of psychopathology. This suggests that the hyperactivating nature that characterises the anxious pattern of attachment (i.e., hypervigilance to threat, excessive dependence on attachment figures for soothing, and a tendency to magnify signs of danger) may be associated with maladaptive emotion regulation techniques (Pascuzzo et al., 2015). When hyperactivating strategies are coupled with a negative model of the self, an individual with attachment anxiety may feel overwhelmed and experience greater hardship in the face of stress, and this may be connected to a heightened experience of premenstrual symptoms (Mikulincer & Shaver, 2016).

Importantly, for women who were currently using HC, there was no evidence of mediation. Among women using HC, pathway “b” (between maladaptive emotion regulation and premenstrual symptoms) remained significant but was smaller relative to the strength of this pathway for women who were naturally cycling; this could be because this relationship is lessened with the use of HC. Yonkers et al. (2017), for instance, observed increases in perimenstrual symptoms in both a group of women who were using HC and a group of women who were not. However, cycle-related increases in depression, anger, irritability, and physical symptoms were greater in the group of women who were not using HC. Thus, the use of HC, through its effect on hormone expression (Blake et al., 2022; Rivera et al., 1999), may attenuate the link between affective experience, maladaptive emotion regulation, and the reporting of premenstrual symptoms.

However, findings regarding the effect of HC on psychological premenstrual symptoms have been mixed (Fruzzetti & Fidecicchi, 2020; Martell et al., 2023), and overall indicate that both HC users and naturally cycling women experience cycle-induced psychological symptoms (Blake et al., 2022). Indeed, in the current study there were no differences between the HC and naturally cycling groups on cycle regularity, premenstrual symptom severity, maladaptive emotion regulation, or anxious attachment. Moreover, the observed relationships between variables in the HC group of women were significant and in the anticipated direction. It is possible that the non-significant mediation effect observed in this sub-group of women currently using HC was a function of diminished statistical power due to the restricted sample size in this sub-group of women (Fritz & MacKinnon, 2007). Replication of this finding is required before concluding that the mediation pathway does not exist for women using HC.

Contrary to expectations, no direct association was identified between attachment anxiety and premenstrual symptom severity when analysing sub-groups of women according to current use of HC. Our findings thereby suggest that women with an anxious attachment may be more prone to experiencing maladaptive emotion regulation, and that it is through this mechanism that women’s premenstrual symptoms may be exacerbated (rather than via a direct relationship with premenstrual symptoms). Also contrary to expectations, findings differed for the avoidant pattern of attachment. Attachment avoidance was not significantly associated with maladaptive emotion regulation or premenstrual symptoms, nor did maladaptive emotion regulation mediate the attachment-premenstrual symptoms pathway under any circumstance. These findings diverge from the positive association between the anxious and avoidant patterns of attachment and maladaptive emotion regulation reported by Pepping et al. (2013). However, the present findings do align with research by Cronin et al. (2018), whereby no association was reported between attachment avoidance and maladaptive emotion regulation. Such an outcome may be explained by the tendency of those with an avoidant attachment to distance themselves from difficult emotions and to employ deactivating emotion regulation strategies (i.e., disengagement from emotion, withdrawal from supports, and emphasis on independence) (Mikulincer & Shaver, 2016).

It is possible that the propensity to disengage from emotions may reduce an individual’s awareness and conscious experience of emotional distress. Consequently, self-report measures which rely on awareness and personal insight may be limited in their ability to identify more covert forms of maladaptive emotion regulation (e.g., suppression) (Mikulincer & Shaver, 2016). Nevertheless, deactivating strategies typically endorsed by those with an avoidant attachment, are also reported to have profound implications for the development of psychopathology (Eftekhari et al., 2009). Future research is important to further elucidate the role of these deactivating emotion regulation strategies in the relationship between avoidant attachment and premenstrual symptoms. In addition, it would be useful to explore additional emotional mechanisms underlying the attachment-premenstrual symptoms relationships, such as the use of more adaptive emotion regulation techniques (Gürdal et al., 2018; Petersen et al., 2016).

Implications and practical applications

Overall, the present findings demonstrate that naturally cycling women with an anxious attachment may experience heightened maladaptive emotion regulation which, in turn, may be positively associated with their experience of premenstrual symptoms. Given that the premenstrual period is a biologically, hormonally, and emotionally tumultuous time for many women, research that illuminates potential gateways for prevention and intervention, is invaluable. The current results highlight the potential utility of psychotherapies that address the attachment relationship when working with naturally cycling women presenting with premenstrual symptoms. Therapies that emphasise co-regulation, emotional processing, and model a secure attachment relationship may be effective in remedying underlying attachment insecurity, and consequently, reducing premenstrual symptom severity in this context (Brenning & Braet, 2013). Indeed, efficacy for improving attachment security and emotion regulation skills has been established for Emotion Focused Therapy and Attachment-Based Psychotherapy (Brenning & Braet, 2013; Costello, 2013). Incorporating these, or similar, therapeutic modalities into the management of severe premenstrual symptomatology may, consequently, alleviate, and potentially prevent, elevated levels of premenstrual distress.

Limitations and future directions

The present study is not without some limitations. Firstly, data was collected cross-sectionally and analysed via correlations, and as such, directionality cannot be assumed. Employing a longitudinal design may aid in elucidating the directionality of the relationships. We also only included participants who experienced menstruation and identified as female in the study. Future research could explore these important relationships in all menstruating people, including LGBTQIA+ and gender-diverse individuals (Kreines et al., 2022).

In relation to measurement, the validity of the measures may have been limited by reliance on self-report. The PMSS relies upon retrospective self-reporting of premenstrual symptoms which has been linked with an overestimation of their frequency (Kepple et al., 2016). Alternative well-validated prospective measures are available (i.e., the Carolina Premenstrual Assessment Scoring System, C-PASS; Eisenlohr-Moul et al., 2017), and prospective measures such as these are considered the gold-standard. However, importantly, prospective measures of premenstrual symptoms are usually positively correlated with retrospective measures. Prospective measures also typically require two or more months of daily symptom ratings which can be burdensome for participants to reliably complete. These pragmatic factors are an important consideration in future investigations in this area (Richards & Oinonen, 2022).

An additional measurement consideration is that individuals with attachment avoidance have been found to overestimate their ability to regulate emotions (Kobak & Sceery, 1988). Scope has been identified for the use of physiological markers (e.g., tracking heart rate) to measure maladaptive emotion regulation in those with an avoidant attachment, to circumvent the drawbacks of self-report measures (Roisman et al., 2004). Relatedly, the lack of inclusion of hormonal assessment limits our capacity to confidently ascertain whether the observed effects reported here, including the non-significant mediation observed in the HC sub-group of women, were linked with changes or differences in hormone (i.e., oestrogen and progesterone) levels (Blake et al., 2022; Rivera et al., 1999).

The attachment measure utilised in the current research also focused predominantly on intimate partner relationships. Given that attachment orientations can vary across different relationships (Cronin et al., 2018), exploring the influence of other forms of attachment relationships may help to illuminate the specific attachment conditions associated with elevated premenstrual symptom severity. Indeed, linking with the importance of measuring hormone levels in future research in this area, higher levels of oestradiol (i.e., a primary form of oestrogen) have been associated with heightened caregiving behaviours and reduced attachment avoidance in intimate relationships (Edelstein et al., 2010, 2012). On a final note, although the present study has established that there is a complex interplay between anxious attachment and maladaptive emotion regulation, and that maladaptive emotion regulation is associated with heightened premenstrual symptoms, we have only explored one potential mechanism underlying this relationship. Theoretically, our pattern of results indicate that it may be the negative view of the self, underpinning the anxious pattern of attachment, that contributed to the observed mediation pathway for these variables. However, future research designed to test this interpretation and examine the specific mechanisms underlying the relationship pathways would be valuable. Such research could inform the development of targeted interventions for women with severe premenstrual symptoms.

Conclusion

To our knowledge, the current study was the first to demonstrate that, after statistically controlling for the influence of age, cycle regularity, and general symptoms of psychopathology, more anxious attachment was indirectly linked with increased premenstrual symptom severity, via heightened maladaptive emotion regulation among a sub-sample of naturally cycling women. Although women’s subjective self-reported experiences are valuable sources of information to guide psychological treatment and intervention in this area, further research is needed which incorporates supplementary physiological and hormonal measurements and investigates additional potential mediating or moderating variables involved in these associations. Importantly, however, the present study has underscored the role that attachment and emotion regulation may play in protecting naturally cycling women from, or rendering them more vulnerable to, experiencing exacerbated premenstrual distress. These new insights have paved the way for future investigations in this important area of research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.