Post-traumatic-stress in the context of childhood maltreatment: pathways from attachment through mentalizing during the transition to parenthood

Introduction

This study aimed to clarify the role of mentalizing in pathways from attachment to Post Traumatic Stress Symptoms (PTSS) in survivors of childhood maltreatment (CM). We focused on the transition to parenting, a critical period for reworking parenting representations to reduce intergenerational maltreatment cycles.

Method

Study participants included 100 pregnant CM survivors. We assessed PTSS with the SCID and attachment and mentalizing with the Adult Attachment Interview (AAI), which was rated for Attachment and Reflective Functioning (RF).

Results

Regarding Re-experiencing trauma symptoms, the results of the path analysis were consistent with mediation. CM survivors' mentalizing about their early relationships with their parents (RF-Other) directly impacted Re-experiencing trauma symptoms, and attachment had an effect on Re-experiencing trauma symptoms through mentalizing (RF-Other). Regarding Arousal/Reactivity symptoms, the results of the pathways analysis were consistent with partial mediation by mentalizing about early relationships with parents (RF-Other). In addition to the pathway from attachment via mentalizing (RF-Other) to Arousal/Reactivity, the pathway between attachment and Arousal/Reactivity also remained significant.

Discussion

This study provides new evidence of a mentalizing and attachment model of PTSS in CM survivors. The findings indicate that increased mentalizing about early relationships with parents is an important process associated with lower PTSS. Finally, we discuss the implications of developing interventions for CM survivors to reduce PTSS. Scaffolding the development of mentalizing regarding attachment relationships in which CM occurred may help CM survivors reduce the intrusion of traumatic memories and decrease trauma-related arousal and reactivity symptoms. Interventions to help CM survivors mentalize regarding parents and attachment relationships in which trauma occurred may be particularly important during the transition to parenting when activation of representations of parenting can trigger PTSS.

The Differential Effects of Insecure Attachment on Post-Traumatic Stress: A Systematic Review of Extant Findings and Explanatory Mechanisms

It is well-documented that insecure attachment poses substantial risks to post-trauma recovery. Although attachment anxiety reliably predicts and is associated with elevated post-traumatic stress symptoms (PTSS), the attachment avoidance-PTSS link has been far less consistent. This suggests both attenuating and enhancing connections between attachment difficulties and post-trauma outcomes. The goal of this study is 2-fold: (a) to review and summarize extant evidence concerning the relation between insecure attachment and PTSS and (b) to review mechanism(s) underlying attachment anxiety and attachment avoidance that may explain the development of PTSS. Following a systematic review of the empirical literature investigating attachment, trauma, and post-trauma reactions, a total of 138 studies were identified and summarized. The review further identifies explanatory mechanisms underlying the association between insecure attachment and PTSS, including stress appraisals, cognitive factors, self-esteem, emotion regulation strategies, social factors, and trauma-specific factors (i.e., type of trauma, extreme stress). Implications for practice, policy, and research are discussed.

Attachment Styles and Posttraumatic Growth Among Suicide-Loss Survivors

Abstract. Background and aims: The world loses approximately one million people to suicide every year, leaving behind many suicide-loss survivors, family members and friends, who are significantly affected by the traumatic loss. Yet some suicide-loss survivors not only manage to cope with the loss, but actually experience posttraumatic growth (PTG). To date, no studies have fully examined the psychological processes that underlie this personal positive change. We hypothesized that attachment style would predict PTG and this association would be mediated by self-disclosure and social support. Method: A community sample of 131 suicide-loss survivors (108 women), aged 18–70, self-reported on attachment style, self-disclosure, social support, and PTG. Results: Securely attached individuals scored highest on PTG compared with other attachment styles. A structural equation model confirmed that self-disclosure and social support mediated the association between attachment and PTG. Suicide-loss survivors with secure attachment tended to self-disclose more and to perceive greater support from others than did suicide-loss survivors with insecure attachment, thus enhancing their chances of PTG. Limitations: The sample comprised mostly female participants, and the findings may not be directly generalizable to male suicide-loss survivors. Conclusion: Our results suggest that different psychological interventions should be utilized for suicide-loss survivors with particular attachment styles. Psychotherapies aiming to modify internal working models may be useful for enhancing PTG among survivors characterized by insecure attachment styles.

The links between adult attachment and post-traumatic stress: A systematic review

PURPOSE

The theory of attachment has informed our understanding of survival and well-being throughout the lifespan. There is a growing interest in the relationship between attachment and symptoms of post-traumatic stress (PTS). Emerging evidence points to important links between attachment and PTS, yet current theoretical and clinical understandings of PTS symptoms and attachment remain relatively disparate. The current systematic review aimed to synthesize, describe, and critique evidence demonstrating the links between attachment and PTS in adults. It also aimed to explore whether the relationship between attachment and PTS differs according to the nature of the traumatic event.

METHODS

Searches were conducted using PsycINFO, the Cochrane Library, Medline, and Google Scholar to identify empirical studies focusing on PTS in adults.

RESULTS

Twenty-one papers were identified. Attachment was shown to have moderating and mediating influences on the relationship between trauma and PTS. This varied according to the type of trauma, and how symptoms of PTS were reported across the different attachment styles. Methodological rigour varied across studies. Clinical and research implications are discussed, including the consideration of attachment security in assessment and formulation.

CONCLUSIONS

Although findings were mixed, this review suggests that there is an important link between attachment and PTS. It supports the current emerging evidence demanding the development of a more unified theoretical framework for attachment, types of trauma, and symptoms of PTS.

PRACTITIONER POINTS

The findings discussed in this review have important implications for the treatment of PTS symptoms. Consideration of attachment styles in formulations is likely to inform treatment plans. There is increasing evidence to suggest that assessing and accounting for attachment style in therapy may improve the chances of successful treatment.

Assessing adult attachment: Relation and validity of two dynamic-maturational model approaches

Assessing attachment is essential yet challenging. The Adult Attachment Interview (AAI) provides the best appraisal of adult attachment but is time-intensive and costly. Likewise, concerns have been raised regarding the Berkeley-AAI coding and classification method. Meanwhile, self-report measures of adult attachment are time-efficient and low-cost, but their validity is questionable. The Dynamic-Maturational Model approach to the AAI (DMM-AAI) and a novel self-report measure – the Attachment Relationship Questionaire (ARQ) – may offer a solution. However, additional investigations regarding the validity of DMM-AAI are needed and the ARQ’s psychometric properties have not be tested. The validity of the DMM approach to the AAI and the predictive relationship between the ARQ and DMM-AAI classification were examined for 212 participants living the UK. Results indicated a strong positive relationship between high numbered attachment classification on the DMM-AAI and psychological treatment status, χ²(6) = 56.07, p < .001; Cramer’s V = .371, p < .001. Binomial logistic regressions between the ARQ and DMM-AAI found both single-statement and multi-statement predictive models were statistically significant. However, the ARQ accounted for only a small amount of the variance (R² ≤ 0.15). In conclusion, the DMM-AAI demonstrated strong construct validity, whereas the ARQ is not useful for assessment of adult attachment. Further investigation with a revised version of the ARQ that addresses psychometric concerns is suggested.

Beyond PTSD and Fear-Based Conditioning: Anger-Related Responses Following Experiences of Forced Migration-A Systematic Review

Introduction: Experiences of forced migration include traumas that are interpersonal in nature, as well as ongoing emotional responses, stress, and frustration in post-migration setti ngs. Open questions exist, regarding anger/anger-like responses following experiences of persecution and ongoing stress. The aim of this study was to explore the adaptive and maladaptive underlying mechanisms of anger/anger-like responses, cultural, linguistic, and social contingencies, and possible interventions for problematic anger behavior. Method: We searched two databases (PsycINFO and PILOTS) with the following search terms: (refugee OR "asylum seek*" OR IDP OR "internal* displac*" OR "forced migra*" OR "involuntary migra*") AND anger. Findings: This search yielded 34 studies that were included in the final review. Although, anger is a moral, adaptive, and prosocial response, dysfunctional anger/anger-like responses arise from PTSD, "moral injury," complicated grief, and independent forms of anger behavior. Cultural, linguistic, and social issues also emerged from the search. Finally, considerations for treatment and intervention are discussed. Discussion: Anger responses following experiences of forced migration may require assessment beyond PTSD models currently framed by DSM and ICD. A very promising framework is the Adaptation and Development after Persecution and Trauma (ADAPT) model. Implications: Further longitudinal and epidemiological research will be necessary to continue testing the ADAPT model and to begin the process of assessing its cross-cultural coherence in other refugee populations (e.g., see Hinton et al., 2003). As anger behavior is also a societal issue, avenues for reconciliation, expression of grievances, employment, civic participation, and integration are needed.

Trajectories of attachment in older age: interpersonal trauma and its consequences

Previous studies suggest that attachment insecurities may increase after trauma exposure, an effect documented only at a group level. This study explores the heterogeneity of changes over time and examines the associations of the nature of the traumatic event (interpersonal and nonpersonal), and its consequences (posttraumatic stress disorder [PTSD] and loneliness) with attachment trajectories. Two groups of Israeli veterans participated: 164 former prisoners-of-war and 185 combat veterans. Attachment was assessed at four points (1991-2015). Risk factors were evaluated in 1991. Using latent growth mixture modeling, trajectories of attachment insecurities were explored. Three avoidance trajectories (stability, decrease, inverse u-shaped) and two anxiety trajectories (stability, decrease) were identified. The inverse u-shaped avoidance trajectory was associated with captivity, humiliation, loneliness, and PTSD, and stable avoidance was associated with loneliness. Stable anxiety was associated with captivity and loneliness. Attachment insecurities can change during aging and persist decades after a trauma. Trauma-related risk factors are related to more deleterious trajectories.

Twofold trauma exposure - the dual function of attachment avoidance

Spouses of traumatized war veterans might suffer from distress following indirect exposure to combat and direct exposure to domestic abuse. Yet the effect of this twofold trauma exposure is far from being fully understood. Theory views attachment security as a personal resource mitigating adversity, whereas attachment insecurities intensify distress. Nevertheless, there are mixed results concerning the effects of attachment in the aftermath of trauma. Furthermore, the role of trauma exposure levels regarding the effects of attachment remains largely uninvestigated. Filling these gaps, this study assessed female military spouses 30 (T1) and 38 (T2) years after the 1973 Yom Kippur War. Direct (domestic abuse) and indirect (veteran partners' posttraumatic stress symptoms) trauma exposure, attachment, depression, and anxiety were assessed. Findings indicated an interaction between the trauma types in predicting spouses' anxiety. Domestic abuse moderated the relations between attachment and distress. Although attachment anxiety had nonsignificant effects on anxiety among low-level domestic abuse sufferers, it predicted elevated anxiety among high-level domestic abuse sufferers. Furthermore, while attachment avoidance predicted elevated distress among low-level domestic abuse sufferers, its effects dissolved or became positive in nature among high-level domestic abuse sufferers. Discussion focuses on evolutionary explanations of the functions of attachment under different conditions of threat.

Attachment Dimensions and Post-traumatic Symptoms Following Interpersonal Traumas versus Impersonal Traumas in Young Adults in Taiwan

Greater risk of post-traumatic stress disorder (PTSD) is seen in individuals exposed to interpersonal traumatic events. Based on an attachment perspective, interpersonal trauma exposure may activate one's attachment insecurity system and disrupt affect, behaviour and interpersonal function, which may in turn create more difficulties to cope with interpersonal traumas and exacerbate PTSD symptomatology. The present study examined whether attachment anxiety relative to attachment avoidance would be a stronger predictor of greater PTSD symptoms following interpersonal traumas versus impersonal traumas in a Taiwanese sample. One hundred and sixty-two trauma-exposed Taiwanese young adults completed the measures of symptoms of depression, anxiety and PTSD, and attachment anxiety and attachment avoidance. In this Taiwanese study, higher attachment anxiety was observed in individuals who were exposed to interpersonal traumas. The interpersonal trauma group reported greater PTSD symptoms than did the impersonal trauma group. Specifically, after controlling for age, occurrence of trauma and distress of trauma, attachment anxiety, but not attachment avoidance, predicted more PTSD total severity and avoidance symptoms in the interpersonal trauma group. The findings may be pertinent to attachment anxiety-related hyperactivating strategies, as well as specific cultural values and a forbearance strategy applied to regulate traumatic distress in a collectivist society. Copyright © 2016 John Wiley & Sons, Ltd.

Attachment representations among substance-abusing women in transition to motherhood: implications for prenatal emotions and mother-infant interaction

We studied how attachment representations contribute to central components of transition to motherhood, prenatal emotion processing (EP) and emotional availability (EA) of mother-infant interaction, and whether there are group specific differences. Participants were 51 treatment-enrolled substance-abusing (SA) mothers and their infants and 50 non-using comparison dyads with obstetric risk. Mother's attachment representations (AAI) and EP were assessed prenatally and EA when infants were four months. Results showed that autonomous attachment only had a buffering effect on prenatal EP among comparisons. All SA mothers showed more dysfunctional EP than comparisons and, contrary to comparisons, autonomous SA mothers reported more negative cognitive appraisals and less meta-evaluation of emotions than dismissing SA mothers. Preoccupied SA mothers showed high negative cognitive appraisals, suggesting under-regulation of emotions. Attachment representations were not associated with EA in either group; rather, SA status contributed to global risk in the relationship. Surprisingly, autonomous SA mothers showed a tendency towards intrusiveness. We propose that obstetric risk among comparisons and adverse relational experiences among almost all SA mothers might override the protective role of mother's autonomous representations for dyadic interaction. We conclude that prenatal emotional turbulence and high interaction risk of all SA mothers calls for holistic treatment for the dyad.

Attachment organization in Arabic-speaking refugees with post traumatic stress disorder

As a part of an ongoing clinical study of refugees with post traumatic stress disorder (PTSD), the primary objective of the current study was to examine and describe the distribution of adult attachment patterns as assessed by the Adult Attachment Interview (AAI) in Arabic-speaking refugees. A total of 43 adult male and female refugees with Iraqi and Palestinian backgrounds completed the AAI. Sixty-seven percent of the sample was classified as Unresolved with respect to loss or trauma and a substantial proportion of insecure attachment representations (14% Secure-Autonomous, 39% Dismissing, 42% Preoccupied, 5% Cannot Classify) was found, in addition to high intake levels of post traumatic stress symptoms and comorbidity. Findings are compared with AAI studies of other PTSD or trauma samples, and the paper elaborates upon the methodological challenges in administering the AAI in a context of simultaneous translation.

Accounting for Posttraumatic Stress Disorder Symptom Severity With Pre- and Posttrauma Measures: A Longitudinal Study of Older Adults

Using data from a longitudinal study of community-dwelling older adults, we analyzed the most extensive set of known correlates of PTSD symptoms obtained from a single sample to examine the measures' independent and combined utility in accounting for PTSD symptom severity. Fifteen measures identified as PTSD risk factors in published meta-analyses and 12 theoretically and empirically supported individual difference and health-related measures were included. Individual difference measures assessed after the trauma, including insecure attachment and factors related to the current trauma memory, such as self-rated severity, event centrality, frequency of involuntary recall, and physical reactions to the memory, accounted for symptom severity better than measures of pre-trauma factors. In an analysis restricted to prospective measures assessed before the trauma, the total variance explained decreased from 56% to 16%. Results support a model of PTSD in which characteristics of the current trauma memory promote the development and maintenance of PTSD symptoms.

Professionally Led Peer Support Group Process After the School Shooting in Finland

Background

Traumatic grief is a risk factor for psychological and physiological impairment. In a school shooting incident in Finland, several people lost their lives, and a large number of bereaved family members were at risk for traumatic grief. Psychosocial support for these bereaved was therefore essential, and this article describes a program that was developed for that purpose.

Method

Professionally led peer support group process was provided for the relatives of the deceased in the school shooting in Kauhajoki, Finland, 2008. The 2-year-long process consisted of five weekend gatherings with psychoeducative and group-work elements. The content of the process was based on the existing knowledge of and recommendations for enhancing recovery after a traumatic loss.

Results

On the average, 50 relatives of the deceased in the school shooting participated in the process. The process was based on the principles of (a) timing of the group work and interventions according to stages of bereavement, (b) psychoeducation, awareness rising, and recognizing the signs of posttraumatic symptoms, (c) attachment theory-based elements in parents' and siblings' grief and group work, and (d) encouraging cohesion and strength of families' natural networks and support systems.

Conclusion

Professionally led peer support group process is a trauma-theory-based intervention, which reaches a large number of the bereaved with similar loss. Via group work, psychoeducation, and shared rituals, the bereaved have an opportunity to share and express emotions and experiences, as well as increase their skills in psychological recovery after a violent death of a family member.

Trajectories of posttraumatic stress symptoms (PTSS) after major war among Palestinian children: Trauma, family- and child-related predictors

OBJECTIVE

Research shows great individual variation in changes in posttraumatic stress symptoms (PTSSs) after major traumas of terrorist attacks, military combat, and natural disasters. Earlier studies have identified specific mental health trajectories both in children and adults. This study aimed, first, to identify potential PTSS-related trajectories by using latent class growth analyses among children in a three-wave assessment after the 2008/2009 War on Gaza, Palestine. Second, it analyzed how family- and child related factors (e.g., attachment relations, posttraumatic cognitions (PTCs), guilt, and emotion regulation) associate with the trajectory class membership.

METHODS

The sample consisted of 240 Palestinian children (49.4% girls and 50.6% boys) of 10-13 years of age (M=11.29, SD=0.68), who completed PTSS (CRIES) assessments at 3 (T1), 5 (T2), and 11 (T3) months after the war. Children reported their personal exposure to war trauma, attachment style, cognitive trauma processing, and emotion regulation, and their parents reported family war trauma exposure and attachment style.

RESULTS

Results revealed a three-trajectory solution, a majority of children belonging to the Recovery trajectory (n=183), and a minority belonged either to Resistant trajectory (n=29) or to Increasing symptoms trajectory (n=28). Low levels of negative posttraumatic cognitive appraisals, feelings of guilt and emotion regulation were characteristic of children in the Resistant trajectory as compared to Increasing symptoms trajectory. Father׳s attachment security was further associated with the Resistant trajectory membership. Children׳s attachment avoidance and high parental trauma were typical to children in Recovery trajectory (as compared to the Increasing symptoms trajectory).

The role of attachment in recovery after a school-shooting trauma

BACKGROUND

Survivors of life-endangering trauma use varying resources that help them to recover. Attachment system activates in the times of distress, and is expected to associate with stress responses, arousal regulation, and mental health.

OBJECTIVE

We examined the associations of attachment style with posttraumatic stress disorders (PTSD) symptoms and dissociative symptoms, and posttraumatic growth (PTG) among students exposed to a school shooting in Finland in a three-wave follow-up setting.

METHOD

Participants were students (M age=24.9 years; 95% female) who were followed 4 (T1, N=236), 16 (T2, N=180), and 28 months (T3, N=137) after the shooting. The assessments included the Attachment Style Questionnaire, the Impact of Event Scale, part of the Adolescent Dissociative Experiences Scale and the Posttraumatic Growth Inventory.

RESULTS

Securely attached survivors had lower levels of posttraumatic stress and dissociative symptoms than preoccupied at T1 and T2 as hypothesized. At T3 survivors with avoidant attachment style had higher levels of intrusive and hyperarousal symptoms than those with secure style. Concerning PTG, survivors with avoidant attachment style scored lower in PTG at T3 than survivors with both secure and preoccupied style.

CONCLUSION

Secure attachment style was beneficial in trauma recovery. A challenge to the health care systems is to acknowledge that survivors with preoccupied and avoidant attachment styles react uniquely to trauma, and thus need help in different doses, modalities, and timings.

Attachment and mental health symptoms among U.S. Afghanistan and Iraq veterans seeking health care services

Attachment theory has become a primary framework for understanding adjustment to traumas. In a convenience sample of 157 U.S. service members from the Afghanistan and Iraq wars seeking health care services at a Veterans Administration (VA) hospital, this study examined (a) the impact of attachment characteristics on several key mental health symptoms in this new generation of veterans, (b) the relative frequencies of prominent attachment styles in the sample, and (c) how these higher order orientations related to study outcomes. First, with demographic and military background factors in the model, attachment-related anxiety and avoidance were each uniquely associated with posttraumatic stress symptoms (PTSS), psychiatric distress, and alcohol misuse, βs = .25 to .60. Second, latent class analysis highlighted the underrepresentation of avoidant veterans of a dismissive type in the sample. Third, of the different possible types of attachment insecurities, veterans with a fearful disorganized orientation were also shown to be particularly vulnerable to PTSS and other problems, even when compared to preoccupied-dependent persons. These findings yield further support for the protective benefit of attachment security, while also suggesting the importance of both attachment anxiety and avoidance in the context of postdeployment adjustment.

Emotion regulation strategies as mediators of the association between level of attachment security and PTSD symptoms following trauma in adulthood

Although, a link between attachment and posttraumatic stress disorder (PTSD) symptoms has been established, the mechanisms involved in this link have not yet been identified. Furthermore, attachment has been systematically measured by self-report questionnaires, which are prone to perceptual bias. The first goal of this study was to examine the link between PTSD symptoms and attachment security level, as measured with a security index created from the Adult Attachment Projective interview. The second goal was to test emotion regulation strategies as mediators of this link. Participants were recruited in hospital emergency rooms following trauma exposure in adulthood. The results showed that a higher level of attachment security was associated with fewer PTSD symptoms at one and three months post-trauma. The results also showed that substance use and emotion-focused strategies mediated the association between attachment and PTSD symptoms. Theoretical and clinical considerations that follow from these outcomes are discussed.

Predictors of psychological distress and positive resources among Palestinian adolescents: trauma, child, and mothering characteristics

OBJECTIVE

The aim was to examine how traumatic and stressful events, responses to violence, child characteristics, and mothering quality, as measured in middle childhood predict psychological distress and positive resources in adolescence.

METHOD

The participants were 65 Palestinian adolescents (17+/-.85 years; 52% girls), who had been studied during the First Intifada (T1), during the Palestinian Authority rule (T2) and before the Second Al Aqsa Intifada (T3) in Gaza. Psychological distress was indicated by PTSD, and depressive symptoms and positive resources by resilient attitudes and satisfaction with quality of life, all measured at T3. The predictors that were measured at T1 were exposure to military violence, active coping with violence and children's intelligence, cognitive capacity, and neuroticism. Mothering quality and stressful life-events were measured at T2, the former reported by both the mother and the child, and the latter by the mother.

RESULTS

Adolescents' PTSD symptoms were most likely if they had been exposed to high levels of traumatic and stressful experiences and had poor cognitive capacity and high neuroticism in middle childhood. Only high levels of childhood military violence and stressful life-events predicted high depressive symptoms and low satisfaction with quality of life in adolescence.

CONCLUSIONS

Military violence in childhood forms risks for both increased psychological distress and decreased positive resources. However, child characteristics such as cognitive capacity and personality are important determinants of psychological vulnerability in military trauma.

The deterioration and mobilization effects of trauma on social support: childhood maltreatment and adulthood military violence in a Palestinian community sample

OBJECTIVES

To show that exposure to childhood maltreatment deteriorates, whereas exposure to adulthood military violence mobilizes social support; second, to show that associations between traumatic events and mental health problems are mediated through social support and, subsequently, adulthood military violence is associated with low level and childhood maltreatment with high level of mental health symptoms; third, to explore whether the moderating (protecting) effect of sufficient and satisfactory social support would differ among victims of childhood maltreatment and adulthood military violence.

METHOD

The participants were a random-sample of Palestinian men and women (n=585) of 16-60 years of age. Exposure to military violence in adulthood was assessed by the Harvard Trauma Questionnaire (HTQ_I), and to childhood maltreatment by a 13-item questionnaire developed for the study. A Social Network Schedule was applied to assess the function, source, and satisfaction with social support, and the Revised SCL90-R Symptoms Checklist to assess mental health symptoms.

RESULTS

Findings supported our hypothesis that exposure to childhood maltreatment was associated with low levels of social support, whereas exposure to adulthood military violence was associated with high levels of social support. Contrary to our second hypothesis, both childhood maltreatment and adulthood military violence were associated with high levels of mental health symptoms. Finally, high level and satisfactory social support moderated the association between exposure to military violence in adulthood and mental health symptoms, but not between childhood maltreatment and mental health symptoms.

CONCLUSION

The findings emphasize that the nature of trauma, that is, whether familial or political, determines the availability of protective resources versus vulnerability, which should be considered when tailoring interventions to trauma victims.