Assessing adult attachment after out-of-hospital cardiac arrest: an exploratory analysis and construct validation of the ECR-RS

Nanna Hansen; Cæcilia von Tangen Gehrt Sivertsen; Dea Siggaard Stenbæk; Mitti Blakoe; Camilla Dichman; Bo Gregers Winkel; Anders Wieghorst; Britt Borregaard; Mette Kirstine Wagner

doi:10.1016/j.resplu.2025.101209

Assessing adult attachment after out-of-hospital cardiac arrest: an exploratory analysis and construct validation of the ECR-RS

Resusc Plus. 2025 Dec 24:27:101209. doi: 10.1016/j.resplu.2025.101209. eCollection 2026 Jan.

Authors

Affiliations

¹ Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
² Neurobiology Research Unit, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
³ Department of Psychology, University of Copenhagen, Copenhagen, Denmark.
⁴ Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.
⁵ Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
⁶ Department of Cardiology, Odense University Hospital, Odense, Denmark.

Abstract

Aim: To explore the construct validity of the 'Experience in Close Relationships - Relationship Structures'-questionnaire (ECR-RS) in a population of out-of-hospital cardiac arrest (OHCA) survivors. Objectives were to (i) describe item- and scale-level response patterns, and (ii) evaluate the preliminary construct validity of the ECR-RS, including its dimensional (structural), known-groups, and convergent validity.

Methods: An exploratory cross-sectional validation study, with OHCA survivors completing the ECR-RS, Hospital Anxiety and Depression Scale (HADS), and the mental health component from the Short Form-12 (SF-12 MCS) three months post- arrest. Descriptive statistics and floor/ceiling analyses were performed. Dimensional validity was assessed using response distribution patterns and exploratory factor analysis (EFA), followed by reliability using Cronbach's άs. Known-group validity was tested using a priori hypotheses, Spearman's correlations, and Mann-Whitney U tests. Convergent validity was evaluated by correlating ECR-RS total scores with HADS and SF-12 MCS.

Results: Among 123 survivors (median age 59.9 years, 84 % male), ECR-RS total scores were low on both subscales and floor effects were observed at scale level (31 % for avoidant and 72 % for anxious attachment). EFA supported the expected two-factor structure, though item 4-6 showed poor loadings/cross-loadings. Internal consistency was acceptable (total scale Cronbach's α = 0.88) and improved when problematic items were excluded. Known-group hypotheses were not supported. Anxious attachment correlated moderately with symptoms of anxiety and depression and was inversely correlated with mental health scores.

Conclusion: The ECR-RS demonstrated partial construct validity among OHCA survivors, but item-level inconsistencies and pronounced floor effects limit its utility. Findings highlight the need for a revised instrument better suited to post-cardiac arrest relational and psychological dynamics.

Keywords: Cross-sectional study; Interpersonal relations; Patient-reported outcome; Psychometric; Resuscitation.