Attachment, social cognition, and posttraumatic stress symptoms in a traumatized, urban population: evidence for the mediating role of object relations

[Old age and attachment theory, a systematic review of attachment typology, continuity, prevalence and association with psychological and health variables in older adults]

The aim of this paper is to review the research on attachment theory during old age in the last 10 years, in order to obtain: a) the prevalence of different types of attachment, b) the assessment of attachment methods, c) the relationship established between attachment and other psychosocial and health variables in the aging process. A systematic search of PsycINFO, PsycArticles, WOS, and Scopus identified 17 studies, in which attachment had been assessed in a population of 7118 older adults. The results of this research present a clear evolution and some differences, with respect to the previous systematic 2010 review. Regarding the prevalence of the different types of attachment, it is confirmed that secure attachment and avoidant attachment are more abundant in old age than in adulthood or youth people. There is no consensus on the instruments used for the evaluation, and results are presented that associate insecure attachment with depression, life satisfaction, physical illness and loneliness. The attachment construct appears as an explanatory and mediating variable, directly involved in the psychology and psychopathology of old age.

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 Efficacy of Two Group Interventions on Mental Representations, Attachment Security, and Trauma Symptoms in Ethnically and Socioeconomically Minoritized Young Adolescents in an Urban Middle School

Symptoms resulting from childhood trauma can negatively impact socioemotional well-being and school performance during early adolescence unless positive changes in attachment security and mental representations of significant relationships occur. A sample of 109 eighth grade urban students were randomly assigned to one of two weekly, one-hour, school-based group interventions-Storytelling/Story-Acting for Adolescents (STSA-A) or Mentalization-Based Treatment Group Intervention (MBT-G). The Object Relations Inventory (ORI), Adolescent Attachment Questionnaire (AAQ) and Child PSTD Stress Scale (CPSS) were administered to students and their primary group leaders at the beginning (October) and end (May) of the intervention protocol as outcome variables. Participants in both the STSA-A and MBT-G intervention conditions experienced significant increases in attachment security and decreases in trauma symptoms. Over the course of eight months of group intervention, affective valence of paternal mental representations significantly decreased for boys and for participants in the STSA-A condition, while affective valence of primary group leader mental representations significantly decreased for participants in the MBT-G condition. STSA-A and MBT-G were found to be efficacious at improving attachment security and reducing trauma symptoms in young adolescents. The strengths of each group intervention for addressing interpersonal issues unique to specific types of adolescents are discussed.

Attachment processes in posttraumatic stress disorder: A review of mechanisms to advance theories and treatments

Current conceptualisations of posttraumatic stress disorder (PTSD) are driven by biological, learning, and cognitive models that have shaped current treatments of the disorder. The strong influence of these models has resulted in a relative neglect of social mechanisms that can influence traumatic stress. There is abundant evidence from experimental, observational, and clinical studies that social factors can moderate many of the mechanisms articulated in prevailing models of PTSD. In this review it is proposed that attachment theory provides a useful framework to complement existing models of PTSD because it provides explanatory value for social factors can interact with biological, learning, and cognitive processes that shape traumatic stress response. The review provides an overview of attachment theory in the context of traumatic stress, outlines the evidence for how attachment factors can moderate stress responses and PTSD, and considers how harnessing attachment processes may augment recovery from and treatment of PTSD. This review emphasizes that rather than conceptualizing attachment theory as an independent theory of traumatic stress, there is much to gain by integrating attachment mechanisms into existing models of PTSD to accommodate the interactions between cognitive, biological, and attachment processes.

Insecure Adult Attachment Style and PTSD Symptom Severity among Firefighters: The Role of Distress Tolerance

Trauma exposure and posttraumatic stress disorder (PTSD) symptoms among firefighters are prevalent and well-documented. Insecure adult attachment style (AAS) and distress tolerance (DT) present two factors with demonstrated relevance to the etiology and maintenance of PTSD. Few studies have examined these constructs in relation to PTSD symptomatology among firefighter populations. The present investigation examined the indirect effect of insecure romantic AAS (i.e., anxious AAS, avoidant AAS) on PTSD symptom severity through DT among firefighters. Exploratory analyses examined this model with each of the PTSD symptom clusters as outcomes. The sample was comprised of 105 firefighters (Mage=40.43, SD=9.15, 95.2% male) recruited from various departments in the southern U.S. An indirect effect was calculated using 10,000 bootstrapped samples. Indirect effects models in the primary analyses were significant when both anxious AAS (β=.20, SE=.10, CI=.06-.43) and avoidant AAS (β=.28, SE=.12, CI=.08-.54) were evaluated as predictors. Effects were evident after accounting for gender, relationship status, years of fire service, and trauma load (i.e., number of potentially traumatic event types experienced). Exploratory analyses revealed that anxious and avoidant AAS are both indirectly related to the PTSD intrusion, negative alterations in cognitions and mood, and alterations in arousal and reactivity symptom clusters through DT. Anxious AAS also demonstrated an indirect association with PTSD avoidance symptoms through DT. Attachment styles may influence PTSD symptoms among firefighters through a firefighter's perceived ability to withstand emotional distress. This line of inquiry has potential to inform specialized intervention programs for firefighters. Clinical and empirical implications are discussed.

Malevolent object relations: A multimethod study of female survivors of childhood abuse

Although childhood victimization is associated with impairments in object relations, it is not clear how different measures comparatively perform in assessing this relationship. This study examined the connection between emotional, physical, and sexual abuse in childhood and three methods of assessing malevolent object representations. Sixty adult women, recruited from an urban primary-care clinic, were administered the Thematic Apperception Test (TAT), the Object Relations Inventory (ORI) interview, and a version of the Early Memories Test (EMT)/interview. Ratings of malevolent object relations were obtained using the affect-tone dimension from the Social Cognition and Object Relations (SCORS-G) scale with both TAT and early memory narratives and through Malevolence ratings from the ORI interview. It was found that, outside of emotional abuse, ORI interview ratings of malevolence consistently differentiated adult childhood abuse groups and nonabuse groups, whereas early memory ratings of malevolence differentiated groups in two of four analyses. Malevolence ratings based upon TAT ratings failed to differentiate any type of abuse from nonabuse. These findings suggest that the use of malevolence ratings from the ORI and early memory narratives are preferred methods for assessing malevolent object relations in urban-dwelling women who have been victimized as children.

The roles of attachment and emotion dysregulation in the association between childhood maltreatment and PTSD in an inner-city sample

BACKGROUND

Most people will experience a traumatic event in their lifetime, but only a subset (<10%) will develop posttraumatic stress disorder (PTSD).

OBJECTIVE

To facilitate prevention and intervention of PTSD, it is important to understand how risk and resilience factors interact with one another to explain individual differences in risk for PTSD, especially in underprivileged groups, who often experience greater burden of trauma and PTSD.

METHOD

The current study utilized multiple and moderated regression to examine the relation between childhood maltreatment and adulthood PTSD risk in the context of various attachment patterns and emotion dysregulation in a sample (n = 856) of mostly low-income, African American participants.

RESULTS

Moderation analysis indicated that the strongest association between self-reported childhood maltreatment and PTSD symptoms was manifest in participants reporting the highest levels of both attachment anxiety and attachment avoidance (b = 0.22, 95% CI [0.15, 0.29], p < .001), whereas, among those low on both these dimensions (i.e., more securely attached participants), there was no significant association between childhood maltreatment and current PTSD (b = 0.07, 95% CI [-0.01, 0.14], p = .07). Separately, multiple regression predicting current PTSD symptoms revealed an effect size for the two attachment dimensions similar to that of emotion dysregulation, while controlling for childhood maltreatment.

CONCLUSIONS

These findings suggest more secure attachment may buffer against the deleterious effects of childhood maltreatment, and both attachment difficulties and emotion dysregulation serve as robust correlates of adulthood PTSD.

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.

Vulnerability Factors Associated with Lifetime Posttraumatic Stress Disorder among Veterans 40 Years after War

Vulnerability factors for posttraumatic stress disorder (PTSD) development are still controversial. Our aim was to study the vulnerability factors for the development of war-related PTSD over a period of 40 years after exposure. A cross-sectional, observational study was carried out on 61 male traumatized war veterans, taking into consideration adverse childhood experiences (ACE), attachment orientations, number of non-war-related traumatic events, and war experiences. Lifetime PTSD was assessed by using the Clinician-Administered PTSD Scale. Insecure attachment styles were significantly associated with lifetime PTSD and even after adjustment for war exposure this was still significant. Non-war-related traumatic events were not associated with lifetime PTSD, whereas ACE were associated with lifetime PTSD. War-related experiences were also associated with lifetime PTSD, except for injury or disease. The results for our sample show that, 40 years after war, the intensity of war-related experiences and ACE were significantly and independently associated with the development of lifetime PTSD. Insecure attachment was significantly associated with lifetime PTSD, which, in turn, are both positively associated with war exposure. These findings may have implications for patient care, as they constitute a strong argument that attachment-focused therapies could well be necessary 40 years after trauma.

Ontological insecurity II: Relationship to attachment, childhood trauma, and subclinical psychotic-like experiences

OBJECTIVES

To examine ontological insecurity as a predictor of positive psychotic-like experiences (PLEs) relative to concepts of childhood trauma, parental bonding, and adult attachment style.

METHODS

A nonclinical sample (N = 298) completed the Ontological Insecurity Scale (OIS-34), a new measure of ontological insecurity, along with measures of the above concepts.

RESULTS

The OIS-34 accounted for a significantly greater proportion of unique variance in positive PLEs than any other theoretical variable. Anxious and avoidant adult attachment were also strongly associated with positive PLEs, but these relationships were mediated by the OIS-34, ceasing to be significant once this latter variable entered the hierarchical regression equation.

CONCLUSIONS

The results are consistent with R. D. Laing's theory that ontological insecurity plays a significant role in psychosis. Moreover, the results suggest that this concept may mediate the established relationship between anxious/avoidant adult attachment and positive PLEs. Implications for psychological approaches to clinical psychosis are discussed.

The relationship between adult attachment style and post-traumatic stress symptoms: A meta-analysis

There is increasing evidence that adult attachment plays a role in the development and perseverance of symptoms of posttraumatic stress disorder (PTSD). This meta-analysis aims to synthesise this evidence and investigate the relationship between adult attachment styles and PTSD symptoms. A random-effects model was used to analyse 46 studies (N=9268) across a wide range of traumas. Results revealed a medium association between secure attachment and lower PTSD symptoms (ρˆ=-.27), and a medium association, in the opposite direction, between insecure attachment and higher PTSD symptoms (ρˆ=.26). Attachment categories comprised of high levels of anxiety most strongly related to PTSD symptoms, with fearful attachment displaying the largest association (ρˆ=.44). Dismissing attachment was not significantly associated with PTSD symptoms. The relationship between insecure attachment and PTSD was moderated by type of PTSD measure (interview or questionnaire) and specific attachment category (e.g. secure, fearful). Results have theoretical and clinical significance.

Post-traumatic stress disorder symptoms in first-time myocardial infarction patients: roles of attachment and alexithymia

AIMS

To explore the roles of attachment and alexithymia in the severity of post-traumatic stress disorder symptoms and to specify the relationship between sub-dimensions of attachment, alexithymia and posttraumatic stress disorder symptoms in patients with first-time myocardial infarction in mainland China.

BACKGROUND

Patients experiencing myocardial infarction have a risk of developing post-traumatic stress disorder symptoms. However, there have been few studies on the roles of attachment and alexithymia.

DESIGN

A cross-sectional survey design.

METHODS

Ninety-seven patients participated in the assessment of post-traumatic stress disorder symptoms, attachment and alexithymia from June-December in 2012. To assess post-traumatic stress disorder symptoms and their correlates, we administered the Post-traumatic Stress Disorder Checklist-Civilian Version, the 20-item Toronto Alexithymia Scale and the Experiences in Close Relationships Scale 5-17 days after the remission of first myocardial infarction attack.

RESULTS

Twenty-five (25·77%) patients met the criteria of posttraumatic stress disorder symptoms. Greater attachment anxiety and avoidance were associated with more severe posttraumatic stress disorder symptoms. Except for externally oriented thinking, all dimensions of alexithymia were significantly correlated with post-traumatic stress symptoms. In the regression model, attachment anxiety and difficulties identifying feelings were found to be predictive and the total regression equation explained 24·2% variance of posttraumatic stress disorder symptoms among myocardial infarction patients.

CONCLUSION

First-time myocardial infarction patients were at risk of developing posttraumatic stress disorder symptoms. Attachment anxiety and difficulties identifying feelings were positively associated with posttraumatic stress disorder symptoms in the early stage of myocardial infarction rehabilitation. It is essential to evaluate the causal relationship between attachment, alexithymia and posttraumatic stress disorder symptoms in longitudinal studies.

Insecure attachment is associated with paranoia but not hallucinations in psychotic patients: the mediating role of negative self-esteem

BACKGROUND

A growing body of research has investigated associations between insecure attachment styles and psychosis. However, despite good theoretical and epidemiological reasons for hypothesising that insecure attachment may be specifically implicated in paranoid delusions, few studies have considered the role it plays in specific symptoms.

METHOD

We examined the relationship between attachment style, paranoid beliefs and hallucinatory experiences in a sample of 176 people with a diagnosis of schizophrenia spectrum disorders and 113 healthy controls. We also investigated the possible role of negative self-esteem in mediating this association.

RESULTS

Insecure attachment predicted paranoia but not hallucinations after co-morbidity between the symptoms was controlled for. Negative self-esteem partially mediated the association between attachment anxiety and clinical paranoia, and fully mediated the relationship between attachment avoidance and clinical paranoia.

CONCLUSIONS

It may be fruitful to explore attachment representations in psychological treatments for paranoid patients. If future research confirms the importance of disrupted attachment as a risk factor for persecutory delusions, consideration might be given to how to protect vulnerable young people, for example those raised in children's homes.

External Validity of SCORS-G Ratings of Thematic Apperception Test Narratives in a Sample of Outpatients and Inpatients

Abstract. The Social Cognition and Object Relations Scale-Global Ratings Method (SCORS-G; Stein, Hilsenroth, Slavin-Mulford, & Pinsker-Aspen, 2011 ) is a reliable system for coding narrative data, such as Thematic Apperception Test (TAT) stories. This study employs a cross-sectional, correlational design to examine associations between SCORS-G dimensions and life events in two clinical samples. Samples were composed of 177 outpatients and 57 inpatients who completed TAT protocols as part of routine clinical care. Two experienced raters coded narratives with the SCORS-G. Data on the following clinically relevant life events were collected: history of psychiatric hospitalization, suicidality, self-harming behavior, drug/alcohol abuse, conduct-disordered behavior, trauma, and education level. As expected, the clinical life event variable associated with the largest number of SCORS-G dimensions was Suicidality. Identity and Coherence of Self was related to self-harm history across samples. Emotional Investment in Relationships and Complexity of Representations were also associated with several life events. Clinical applications, limitations of the study, and future directions are reviewed.