Changes in attachment dimensions during the treatment of acute post-traumatic stress disorder in sexually assaulted Brazilian women

Introduction

Attachment patterns are established during early childhood; however, extreme experiences throughout life may change this structure, either toward attachment security or insecurity. We analyzed changes in attachment dimensions in women with acute post-traumatic stress disorder (PTSD) following sexual assault, that were randomized to a 14-week treatment with either the medication sertraline or Interpersonal Psychotherapy.

Methods

Seventy-four adult women who presented significant reduction in PTSD symptoms across the trial responded to the Revised Adult Attachment Scale at baseline, on week 8 of treatment, and at the end of the trial, on week 14. We fitted a generalized linear model to explain the attachment anxiety and avoidance scores at baseline. A generalized linear mixed model investigated how attachment dimensions changed over time. Socioeconomic data, treatment type, history of childhood trauma, and PTSD severity over the 14-week period were the considered covariates.

Results

At baseline, attachment anxiety was associated with a history of early trauma. Attachment anxiety remained stable during the follow-up. Attachment avoidance, on the other hand, significantly increased from baseline to week 14. Higher avoidance was observed in patients with higher total PTSD scores and on the cluster of hyperarousal symptoms. Races other than White (black, mixed-race, or Asian) and younger age were associated with higher attachment avoidance.

Discussion

Contrary to our expectations, attachment avoidance increased during follow-up, indicating changes in the interpersonal realm beyond the symptoms of PTSD.

When Staying Home Is Not Safe: An Investigation of the Role of Attachment Style on Stress and Intimate Partner Violence in the Time of COVID-19

Intimate partner violence (IPV) is a major public health concern, with increasing rates of IPV being seen around the world during the COVID-19 pandemic. Previous research has linked the perpetration of IPV and other forms of sexual violence to aspects of romantic attachment psychology, with insecure anxious/preoccupied attachment most often linked to higher rates of IPV. Stressful events typically activate the attachment system and may either aggravate or disrupt its regulatory functioning. In the present study, we investigated whether COVID-related PTSD and depressive symptoms were associated with increased IPV perpetration and whether this relationship was moderated by levels of attachment security. Our findings indicated that higher COVID-related PTSD was significantly associated with increased IPV perpetration in securely attached individuals, whereas depressive symptoms was significantly associated with decreased IPV perpetration in securely attached individuals. IPV perpetration by insecure individuals was consistently high regardless of COVID-related PTSD or depressive symptoms. These findings suggest that COVID-related PTSD may erode adaptive attachment functioning, particularly among the previously secure, which can have important consequences for secure individuals and their intimate partners. The present findings may explain some of the recent increase in IPV cases worldwide and serve to raise awareness and motivate clinical interventions to more efficiently help both victims and perpetrators of IPV stay safe while staying home.

Activating the attachment system modulates neural responses to threat in refugees with PTSD

Social attachment systems are disrupted for refugees through trauma and forced displacement. This study tested how the attachment system mitigates neural responses to threat in refugees with posttraumatic stress disorder (PTSD). Refugees with PTSD (N = 28) and refugee trauma-exposed controls (N = 22) viewed threat-related stimuli primed by attachment cues during a functional magnetic resonance imaging scan. Group differences and the moderating effects of avoidant or anxious attachment style and grief related to separation from family on brain activity and connectivity patterns were examined. Separation grief was associated with increased amygdala but decreased ventromedial prefrontal cortical (VMPFC) activity to the attachment prime and decreased VMPFC and hippocampal activity to attachment primed threat in the PTSD (vs trauma-exposed control) group. Avoidant attachment style was connected with increased dorsal frontoparietal attention regional activity to attachment prime cues in the PTSD group. Anxious attachment style was associated with reduced left amygdala connectivity with left medial prefrontal regions to attachment primed threat in the PTSD group. Separation grief appears to reduce attachment buffering of threat reactivity in refugees with PTSD, while avoidant and anxious attachment style modulated attentional and prefrontal regulatory mechanisms in PTSD, respectively. Considering social attachments in refugees could be important to post-trauma recovery, based within changes in key emotion regulation brain systems.

Attachment Style Moderates Polygenic Risk for Posttraumatic Stress in United States Military Veterans: Results From the National Health and Resilience in Veterans Study

BACKGROUND

A polygenic risk score (PRS) derived from genome-wide association studies of posttraumatic stress disorder (PTSD) may inform risk for this disorder. To date, however, no known study has examined whether social environmental factors such as attachment style may moderate the relation between PRS and PTSD.

METHODS

We evaluated main and interactive effects of PRS and attachment style on PTSD symptoms in a nationally representative sample of trauma-exposed European-American U.S. military veterans (N = 2030). PRS was derived from a genome-wide association study of PTSD re-experiencing symptoms (N = 146,660) in the Million Veteran Program cohort. Using one-sample Mendelian randomization with data from the UK Biobank (N = 115,099), we evaluated the effects of re-experiencing PRS and attachment style on PTSD symptoms.

RESULTS

Higher re-experiencing PRS and secure attachment style were independently associated with PTSD symptoms. A significant PRS-by-attachment style interaction was also observed (β = -.11, p = .006), with a positive association between re-experiencing PRS and PTSD symptoms observed only among veterans with an insecure attachment style. One-sample Mendelian randomization analyses suggested that the association between PTSD symptoms and attachment style is bidirectional. PRS enrichment analyses revealed a significant interaction between attachment style and a variant mapping to the IGSF11 gene (rs151177743, p = 2.1 × 10^-7), which is implicated in regulating excitatory synaptic transmission and plasticity.

CONCLUSIONS

Attachment style may moderate polygenic risk for PTSD symptoms, and a novel locus implicated in synaptic transmission and plasticity may serve as a possible biological mediator of this association. These findings may help inform interpersonally oriented treatments for PTSD for individuals with high polygenic risk for this disorder.

The effect of attachment security priming and oxytocin on physiological responses to trauma films and subsequent intrusions

To further understand protective mechanisms to prevent post-traumatic stress disorder or assist recovery from psychological trauma, this study investigated whether pharmacological and psychological activation of a secure attachment representation elicits higher felt-security and a related response pattern of reduced physiological arousal and increased parasympathetic activation; and whether it protects individuals from developing intrusions and experiencing distress in the week following exposure to a trauma film. Using a double-blind, experimental mixed factorial design, 101 volunteers received either oxytocin or placebo and either secure attachment or neutral priming before watching a trauma film. We measured felt security as an indicator of the strength of activation of a secure attachment representation, skin conductance and heart rate as indicators of physiological arousal, and high frequency heart rate variability as an indicator of parasympathetic activation during the priming and the film. Participants then completed a seven-day intrusion diary. Secure attachment priming, but not oxytocin administration or the combination of both, was associated with reduced physiological arousal and increased parasympathetic activity during priming. Although secure attachment priming was not related to the absolute number of intrusions or to less perceived distress or physiological arousal during the trauma film, it was associated with lower intrusion-related distress in the 7-days post-testing. Our findings extend previous research that suggests the importance of interventions that address intrusion-related distress for recovery from trauma, and suggest a promising role for secure attachment priming in trauma-focused psychological therapies. We contribute to the growing literature that finds that higher subjective distress during a trauma is associated with higher intrusion-related distress. We discuss theoretical implications and possible mechanisms through which secure attachment priming may exert potential beneficial effects.

Broaden-and-Build Effects of Contextually Boosting the Sense of Attachment Security in Adulthood

According to attachment theory, a sense of attachment security provides a foundation for mental health, social adjustment, and psychological thriving. In this article, we review what has been learned from laboratory experiments on the causal effects of contextually boosting a person’s sense of attachment security. We begin with a brief account of attachment theory and the construct of attachment security. We then review findings from laboratory experiments showing that contextual activation of mental representations of attachment security has beneficial effects on emotion regulation, psychological functioning, and prosocial behavior.

Attachment Orientations Moderate the Self-Amplifying Cycle of Posttraumatic Stress Disorder and Negative Cognitions—A Seven-Year Longitudinal Study

Introduction: We examined whether attachment orientations moderated the self-amplifying cycle of Posttraumatic Stress Disorder (PTSD) and negative cognitions, decades after the trauma ended.

Method: We sampled Israeli veterans from the 1973 Yom Kippur War and assessed PTSD severity and cognitions about the self and the world, twice—35 (T1) and 42 (T2) years after the war. At T1, we assessed participants’ attachment orientations (anxiety, avoidance).

Results: Findings provided support for a self-amplifying cycle of PTSD severity and negative cognitions about others’ benevolence during the seven-year study period. Findings also indicated that this self-amplifying cycle was significant only among veterans who scored relatively high on attachment anxiety but not among those who had less anxious attachment. Attachment avoidance also moderated the prospective contribution of negative cognitions about the self and others to PTSD severity seven years later.

Discussion: The psychological mechanisms underlying the observed effects of attachment orientations were discussed.

Attachment and social support mediate associations between Polyvictimization and psychological distress in early adolescence

The current study assesses associations between multiple experience of traumatic events (polyvictimization), PTSD symptoms (PTSS) and psychiatric symptoms in early adolescence, and explores the mediating roles of attachment orientations and perceived social support in the associations between polyvictimization, PTSS and psychiatric symptoms. In 2001, a representative national sample of 390 Danish eighth-graders (M = 13.95, SD = .37) completed validated self-report questionnaires. Polyvictimization was related to higher PTSS and psychiatric symptoms. Importantly, polyvictimization was significantly linked to high attachment anxiety, which was linked with low perceived social support, which in turn was linked with high PTSS levels and psychiatric symptoms. Polyvictimization might have dire consequences in early adolescence. An individual's high attachment anxiety might be connected with lack of perceived social support, which should be seen as a possible psychological distress mechanism subsequent to exposure to a number of potentially traumatic events.

The trajectory of bombing-related posttraumatic stress disorder among Iraqi civilians: Shattered world assumptions and altered self-capacities as mediators; attachment and crisis support as moderators

This study examined the impact of bombing on posttraumatic stress disorder (PTSD) and psychiatric co-morbidity over time, whether this relationship was mediated by shattered world assumptions and altered self-capacities, and whether the mediational effects were moderated by attachment style and crisis support among Iraqi civilians. One hundred and fifty-nine Iraqi civilians completed questionnaires measuring the aforementioned psychological constructs. Bombing exposure was associated with PTSD and psychiatric co-morbidity over time; 87% and 77% met the criteria for PTSD at baseline and five months respectively. Shattered world assumptions and altered self-capacities mediated the impact of bombing exposure on PTSD and psychiatric co-morbidity over time. The mediational effect for shattered world assumptions was not moderated by attachment style and crisis support. However, the mediational effect for altered self-capacities was moderated by fearful attachment and a medium level of crisis support. To conclude, following bombing, Iraqi civilians' assumptions about the world and others can change. These changes can have long term effects on psychological distress but are not influenced by childhood attachment experiences or the amount of crisis support received. Bombing can also change civilians' perceptions of internal capacities like emotional regulation, particularly those with fearful attachment who rely on crisis support to some extent.

Complex posttraumatic stress disorder (CPTSD) following captivity: a 24-year longitudinal study

Background: The World Health Organization(WHO) International Classification of Diseases, 11th version (ICD-11), has proposed a new trauma-related diagnosis of complex posttraumatic stress disorder (CPTSD), separate and distinct from posttraumatic stress disorder (PTSD). However, to date, no study has examined CPTSD over time. Objectives: This prospective study aimed to examine predictors and outcomes of latent classes of PTSD and CPTSD following war captivity. Method: A sample of 183 Israeli former prisoners of the 1973 Yom Kippur War (ex-POWs) participated in a 24-year longitudinal study with three waves of measurements (T1: 1991, T2: 2008, and T3: 2015). Participants completed validated self-report measures, and their cognitive performance was assessed using the Montreal Cognitive Assessment (MoCA). Results: Estimated rates of PTSD and CPTSD were high at all waves, with PTSD rates higher than CPTSD. A Latent Class Analysis (LCA) identified three main classes at T2: (1) a small class with low probability to meet PTSD and CPTSD clusters criteria (15.26%); (2) a class high only in PTSD symptoms (42.37%) and (3) a class high only in CPTSD symptoms (42.37%). Importantly, higher levels of psychological suffering in captivity at T1 were associated with higher odds of being in the CPTSD class at T2. In addition, CPTSD at T2 was more strongly associated with low self-rated health, functional impairment, and cognitive performance at T3, compared to the PTSD only class. Conclusions: Adulthood prolonged trauma of severe interpersonal intensity such as war captivity is related to CPTSD, years after the end of the war. Exposure to psychological suffering in captivity is a risk factor for future endorsement of CPTSD symptoms. CPTSD among ex-POWs is a marker for future dire mental health and functional consequences.

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.

Traumatization, Loneliness, and Suicidal Ideation among Former Prisoners of War: A Longitudinally Assessed Sequential Mediation Model

Although highly researched among veterans, the underlying mechanisms of suicidal ideation (SI) among former prisoners of war (ex-POWs), especially in the long-term, have rarely been investigated. Furthermore, while posttraumatic stress symptoms (PTSS) and loneliness have been individually associated with veteran SI, and both may be differentially implicated by captivity versus war traumas, the interplay between them has yet to be examined. Filling this gap, the current longitudinal study examined a hypothetical sequential model wherein war captivity, compared with combat-induced trauma, is implicated in worse PTSS, which is then implicated in worse loneliness and PTSS, which together may explain subsequent SI. Two groups of Israeli veterans of the 1973 Yom Kippur War, 163 ex-POWs and 185 matched non-captive veterans were assessed 18 (T1) and 30 (T2) years after the war. Analyses indicated that compared with war, captivity was implicated in worse PTSS, which was implicated in worse loneliness, and these worked in tandem to implicate SI. Loneliness, however, was not directly affected by the type of trauma, nor was its relation to SI linked to its implication in subsequent PTSS. These results may inform future research and clinical practice as the study underscores the importance of both PTSS and loneliness in ex-POWs' long-term SI.

Separation from parents during childhood trauma predicts adult attachment security and post-traumatic stress disorder

BACKGROUND

Prolonged separation from parental support is a risk factor for psychopathology. This study assessed the impact of brief separation from parents during childhood trauma on adult attachment tendencies and post-traumatic stress.

METHOD

Children (n = 806) exposed to a major Australian bushfire disaster in 1983 and matched controls (n = 725) were assessed in the aftermath of the fires (mean age 7-8 years) via parent reports of trauma exposure and separation from parents during the fires. Participants (n = 500) were subsequently assessed 28 years after initial assessment on the Experiences in Close Relationships scale to assess attachment security, and post-traumatic stress disorder (PTSD) was assessed using the PTSD checklist.

RESULTS

Being separated from parents was significantly related to having an avoidant attachment style as an adult (B = -3.69, s.e. = 1.48, β = -0.23, p = 0.013). Avoidant attachment was associated with re-experiencing (B = 0.03, s.e. = 0.01, β = 0.31, p = 0.045), avoidance (B = 0.03, s.e. = 0.01, β = 0.30, p = 0.001) and numbing (B = 0.03, s.e. = 0.01, β = 0.30, p < 0.001) symptoms. Anxious attachment was associated with re-experiencing (B = 0.03, s.e. = 0.01, β = 0.18, p = 0.001), numbing (B = 0.03, β = 0.30, s.e. = 0.01, p < 0.001) and arousal (B = 0.04, s.e. = 0.01, β = 0.43, p < 0.001) symptoms.

CONCLUSIONS

These findings demonstrate that brief separation from attachments during childhood trauma can have long-lasting effects on one's attachment security, and that this can be associated with adult post-traumatic psychopathology.

Attachment style and interpersonal trauma in refugees

BACKGROUND

Refugees can suffer many experiences that threaten their trust in others. Although models of refugee mental health have postulated that attachment securities may be damaged by refugee experiences, this has yet to be empirically tested. This study aimed to understand the relationship between the nature of traumatic experiences sustained by refugees and attachment styles.

METHOD

In a cross-sectional study, treatment-seeking refugees (N = 134) were assessed for traumatic exposure using the Harvard Trauma Questionnaire and Posttraumatic Diagnostic Scale. Attachment style was assessed using the Experiences in Close Relationship Scale.

RESULTS

Whereas gender and severity of interpersonal traumatic events predicted avoidant attachment style (accounting for 11% of the variance), neither these factors nor non-interpersonal trauma predicted anxious attachment.

CONCLUSIONS

Exposure to interpersonal traumatic events, including torture, is associated with enduring avoidant attachment tendencies in refugees. This finding accords with attachment theories that prior adverse interpersonal experiences can undermine secure attachment systems, and may promote avoidance of attachment seeking. This finding may point to an important process maintaining poor psychological health in refugees affected by interpersonal trauma.

A Relational Model for the Intergenerational Transmission of Captivity Trauma: A 23-Year Longitudinal Study

OBJECTIVES

The aversive, long-term toll of war captivity and fathers' combat-induced posttraumatic stress disorder (PTSD) on adult offspring's secondary traumatization (ST) has been recently exemplified. However, the study of potential mechanisms of the intergenerational transmission of trauma to offspring is still lacking. This prospective study aimed to assess the role of fathers' PTSD symptoms (PTSS), paternal parenting, and adult offspring's attachment insecurities in adult offspring's PTSS.

METHOD

A sample of 124 Israeli father-child dyads (80 ex-POW dyads and a comparison group of 44 veteran dyads) completed self-report measures. The fathers participated in three waves of measurements following the Yom Kippur War (T1: 1991, T2: 2003, T3: 2008), while the offspring took part in T4 (2013).

RESULTS

Offspring of ex-POWs with PTSD at T3 reported more PTSS and higher levels of attachment insecurities than offspring of ex-POWs without PTSD and controls at T4. Fathers' proximity to the children and sensitivity to the children's needs were negatively related. Offspring's attachment insecurities were positively related to offspring's PTSS. Importantly, serial multiple mediation model results show that war captivity increased the level of the fathers' PTSD at T2 and T3, which in turn decreased the level of the fathers' parenting at T3, and thereby increased the level of offspring's attachment avoidance at T4, which by its own merit was related to higher levels of adult offspring's PTSS.

CONCLUSIONS

The mechanisms of the intergenerational transmission of captivity-related trauma of veterans' PTSD and paternal parenting, through offspring's attachment insecurities and offspring's PTSS, was exemplified.

Social attachments and traumatic stress

The extent to which we engage with our social world has been central to our survival as a species and, accordingly, is relevant to how we cope with trauma and adversity. This review summarises current knowledge about the importance of social connections from an evolutionary perspective, as well as integrating this with a discussion of prevailing attachment theories. Experimental research supporting the potential benefit of attachments for managing adversity are presented, along with a review of how these benefits are moderated by individual differences in attachment style. The potential impact of trauma on attachment systems, and the manner in which this can compound trauma stress is discussed. Finally, a broader overview of social network analysis is introduced and it is proposed that a more sociocentric framework of trauma response would promote a fuller understanding of how social processes moderate trauma response.

Attachment security and pain--The disrupting effect of captivity and PTSS

The present study assesses the possible disruption effect of posttraumatic stress symptoms (PTSS) with regard to the protective role of attachment on pain, among ex-POWs. While secure attachment seems to serve as a buffer, decreasing the perception of pain, this function may be disrupted by PTSS. The study sample included 104 subjects who were combat veterans of the 1973 Yom Kippur War comprising of 60 male ex-prisoners of war (ex-POWs) and 44 comparable male combat veterans. Both attachment and pain were investigated experimentally in the laboratory and via questionnaires. We found that ex-POWs showed higher levels of clinical pain and attachment insecurities compared to controls. Moreover, attachment avoidance and soothing effect of attachment (SEA) were both associated with lower levels of clinical pain. Most importantly, PTSS moderated the associations between attachment and pain, as well as the mediation role of attachment between captivity and pain. The results imply that although attachment can be an important resource for coping with pain, it can be severely disrupted by PTSS among trauma survivors.

Thinking of attachments reduces noradrenergic stress response

Although there is much evidence that activating mental representations of attachments figure is beneficial for psychological health and can reduce stress response, no research has directly investigated whether attachment activation can ameliorate hormonal stress response. This study investigated whether activating an attachment figure or a non-attachment figure following administration of a socially evaluated cold pressor test to elicit stress impacted on glucocorticoid and noradrenergic response. Participants (N = 61) provided baseline salivary samples, underwent a cold pressor test, then imagined an attachment or non-attachment figure, and finally provided subsequent saliva samples. Participants who imagined a non-attachment figure had greater noradrenergic response following the stressor than those who imagined an attachment figure. These findings highlight that activating attachment representations can ameliorate the immediate noradrenergic stress response.