Attachment style classification and posttraumatic stress disorder in former prisoners of war

Resilience as Mediator in Relation to Parental Attachment and Posttraumatic Stress Disorder in Adolescents Following the Yancheng Tornado

Resilience and secure parental attachment have been proven as important factors to alleviate the posttraumatic stress disorder (PTSD). However, the effects of the two factors on PTSD and the mechanisms of its effect at different time points in the aftermath of trauma are still unclear. This study explores the relationship among parental attachment, resilience, and development of PTSD symptoms in adolescents from a longitudinal perspective following the Yancheng Tornado. Using cluster sampling method, a total of 351 Chinese adolescents, survivors of a severe tornado, were tested on their PTSD, parental attachment and resilience at 12-months and 18-months after experiencing the natural disaster. The results showed that our proposed model fit the data well: χ2/df = 3.197, CFI = 0.967, TLI = 0.950, RMSEA = 0.079. It revealed that the resilience at 18-months partially mediated the relationship between parental attachment at 12-months and PTSD at 18-months. Research results showed that parental attachment and resilience are key resources for coping with trauma.

The brain-body disconnect: A somatic sensory basis for trauma-related disorders

Although the manifestation of trauma in the body is a phenomenon well-endorsed by clinicians and traumatized individuals, the neurobiological underpinnings of this manifestation remain unclear. The notion of somatic sensory processing, which encompasses vestibular and somatosensory processing and relates to the sensory systems concerned with how the physical body exists in and relates to physical space, is introduced as a major contributor to overall regulatory, social-emotional, and self-referential functioning. From a phylogenetically and ontogenetically informed perspective, trauma-related symptomology is conceptualized to be grounded in brainstem-level somatic sensory processing dysfunction and its cascading influences on physiological arousal modulation, affect regulation, and higher-order capacities. Lastly, we introduce a novel hierarchical model bridging somatic sensory processes with limbic and neocortical mechanisms regulating an individual's emotional experience and sense of a relational, agentive self. This model provides a working framework for the neurobiologically informed assessment and treatment of trauma-related conditions from a somatic sensory processing perspective.

Psychological Attachment Orientation and Long-Term Posttraumatic Stress Symptoms Among Family Members of ICU Patients

To determine the degree to which an ICU patient’s family member having an “anxious” psychologic attachment orientation is a risk factor for developing long-term posttraumatic stress disorder (PTSD) symptoms following patient ICU discharge or death.

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.

Examining moderators of the relationship between social support and self-reported PTSD symptoms: A meta-analysis

Social support is one of the most robust predictors of posttraumatic stress disorder (PTSD). Yet, little is known about factors that moderate the relationship between social support and PTSD symptom severity. This meta-analysis estimated the overall effect size of the relationship between self-reported social support and PTSD severity and tested meaningful demographic, social support, and trauma characteristics that may moderate this association using both cross-sectional and longitudinal effect sizes. A comprehensive search identified 139 studies with 145 independent cross-sectional effect sizes representing 62,803 individuals and 37 studies with 38 independent longitudinal effect sizes representing 25,792 individuals. Study samples had to comprise trauma-exposed, nonclinical adult populations to be included in the analysis. Cross-sectional and longitudinal analyses revealed a near medium overall effect size (rcross = -.27; 95% CI [-.30, -.24]; rlong = -.25; 95% CI [-.28, -.21]) with a high degree of heterogeneity (cross-sectional I2 = 91.6, longitudinal I2 = 86.5). Both cross-sectional and longitudinal moderator analyses revealed that study samples exposed to natural disasters had a weaker effect size than samples exposed to other trauma types (e.g., combat, interpersonal violence), studies measuring negative social reactions had a larger effect size than studies assessing other types of social support, and veteran samples revealed larger effect sizes than civilian samples. Several other methodological and substantive moderators emerged that revealed a complex relationship between social support and PTSD severity. These findings have important clinical implications for the types of social support interventions that could mitigate PTSD severity. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.

Understanding the impact of attachment insecurity on PTSD symptoms among male Veterans and military personnel

Attachment insecurity (i.e., attachment anxiety and attachment avoidance) has been found to contribute to PTSD symptom severity in Veterans. However, little is known of the unique contribution of attachment insecurity on individual PTSD symptom clusters. In a community sample of 106 combat-deployed Veterans, active duty service members, and reservists, this study examined: (1) the relationships between childhood family experience, combat experience, attachment insecurity, and PTSD symptom clusters, and (2) the influence of attachment insecurity on PTSD symptom clusters. Results revealed significant correlations between attachment anxiety and all PTSD symptom clusters (rs = .22 -.43) and attachment avoidance and PTSD symptom clusters, except the avoidance cluster (rs = .21 -.36). Four multiple regression analyses were employed to address the second study aim. Childhood family experiences predicted negative alterations in cognitions and mood (β = -.30) and alterations in arousal and reactivity (β = -.20). Further, combat experience significantly predicted each symptom cluster of PTSD (βs = .03 -.44). In the second step, attachment anxiety and attachment avoidance were added to each model. Attachment anxiety and attachment avoidance predicted negative alterations in cognitions and mood (βs = .22 and .35) and alterations in arousal and reactivity (βs = .27 and .17). Inconsistent with previous research, attachment insecurity did not predict symptoms of avoidance. These results highlight the impact of attachment among a diverse sample of trauma exposed individuals and may provide insights for clinical implications and therapeutic approaches when working with Veterans and military personnel high in attachment insecurity.

Prevalence and risk factors of secondary traumatic stress in emergency call-takers and dispatchers - a cross-sectional study

Background: Emergency call-takers and dispatchers (ECDs) field emergency calls and dispatch the appropriate emergency services. Exposure to the callers' traumatic experiences can lead to psychological stress and even to secondary traumatic stress (STS). In addition, previous studies suggest that ECDs may also suffer from posttraumatic stress disorder (PTSD), depression and anxiety disorders. Objectives: To investigate the prevalence of STS and to screen for PTSD, depression and anxiety disorders in ECDs. We further aimed to identify sociodemographic variables and attachment styles as possible risk factors for higher STS symptom load in ECDs. Methods: STS and PTSD regarding lifetime traumatic events, as well as depression and anxiety disorders, were investigated in N = 71 ECDs. Multiple regression analysis was performed to identify possible risk factors for higher STS symptom load. Results: The analysis determined a prevalence of 8.5% for moderate STS and 2.8% for severe STS. A total of 11.3% of the ECDs screened positive for PTSD, 15.5% for depression and 7.0% for anxiety disorders. A higher number of children and the absence of a secure attachment style were identified to be significantly associated with higher STS symptom load. Conclusions: STS resulting from exposure to traumatic emergency caller content is a common phenomenon among ECDs. Specific sociodemographic variables and the attachment style are significant risk factors of STS symptom load. ECDs should receive regular psychoeducational interventions and supervision to identify and mitigate mental distress at an early stage.

Differences in attachment dimensions and reflective functioning between traumatized juvenile offenders and maltreated non-delinquent adolescents from care services

BACKGROUND

Adverse childhood experiences, especially maltreatment, are regarded as significant risk factors for the development of antisocial behavior in adolescence. However, possible correlates are still to be investigated after considering the history of criminal records and the experience of institutionalization.

OBJECTIVE

In this study, differences in attachment anxiety and avoidance, and reflective functioning (RF) between traumatized incarcerated juvenile offenders and non-delinquent adolescents institutionalized in child services because of domestic violence were examined.

PARTICIPANTS, SETTING AND METHOD

Forty-two juvenile offenders (N_female = 19) and 43 inmates of institutions for adolescents without parental care (N_female = 20) with the history of trauma filled in the childhood trauma and attachment dimensions questionnaires, and were scored on the Reflective Functioning Scale. Groups were matched on age and education.

RESULTS

Results indicate that both groups reported equally high levels of attachment anxiety and avoidance. Male juvenile offenders had lower scores on reflective functioning than both female convicted minors (B = 1.06; Odds Ratio = 2.88; Nagelkerkes R² = 45) and non-delinquent adolescents of both genders (B = -.65; Odds Ratio = .52; Nagelkerkes R² = 42). In comparison to non-convicted males, male offenders also had higher scores on the control scale of idealization (B = .35; Odds Ratio = 1.42; Nagelkerkes R² = 42). No differences between females with and without a history of crimes were found.

CONCLUSIONS

Results indicate a need for building RF in both traumatized samples, especially in male delinquents, and encourage further research in females.

Parental attachment, coping, and psychological adjustment among adolescents following an earthquake: a longitudinal study

Background and objective: The study aim was to examine the predictive effect of parental attachment on positive psychological outcomes (posttraumatic growth, PTG) and negative psychological outcomes (posttraumatic stress disorder (PTSD) and depression symptoms), and to test the mediating role of positive and negative coping in the relationship among adolescents following an earthquake in China. Design: The study used a longitudinal design with a 6-month time interval. Method: Data was collected from middle schools in the most severely affected areas at 18 and 24 months following an earthquake. Data were analyzed from 398 adolescents who completed self-report measures of parental attachment, coping, PTSD, depression, and PTG. Path analysis was conducted to examine the relationships among the main study variables. Results: Secure parental attachment predicted lower PTSD and depression symptoms at 24-months follow-up, and negative coping partly mediated the effects of parental attachment on PTSD and depression. No significant association was observed between parental attachment and PTG. Conclusions: The findings indicate that secure parental attachment had a protective effect for adolescents after the disaster. Such attachment may reduce the use of negative coping and in turn decrease psychological distress over time.

Attachment, coping, and psychological symptoms among military veterans and active duty personnel

Background and Objectives: Military service is a stressful occupation, including increased risk for psychological distress. In order to provide the best care for service members and veterans (SMVs), it is important to understand personality and behavioral patterns associated with negative outcomes. This study examined links between attachment processes, coping styles, problematic alcohol use and psychological distress.Design: Using a cross-sectional, correlational design, a multi-instrument survey was administered to participants either online or in-person.Methods: Veterans and active duty service members (N = 268) completed measures of adult attachment, coping styles, alcohol use, and psychological symptoms.Results: Attachment avoidance was positively associated with avoidant coping, alcohol use, depression, and PTSD symptoms, but negatively related to problem-focused coping. Attachment anxiety was associated with avoidant coping, depression, GAD, and PTSD symptoms. Avoidant coping, but not problem-focused coping, was associated with psychological symptoms, and significant indirect relationships were noted between insecure attachment processes, avoidant coping, and psychological symptoms.Conclusion: Findings highlight personality and behavioral factors that may be important treatment foci when working with SMVs. Future studies should evaluate this model using longitudinal designs.

The intergenerational sequelae of war captivity: the impact of a self-amplifying cycle of PTSD and attachment insecurities on offspring's attachment orientations

Background: War captivity is one of the most severe human-made traumatic events which lead to self-amplifying cycle of post-traumatic stress disorder (PTSD) symptoms and attachment insecurities. Solid evidence in the literature pointed out on the intergenerational transmission of PTSD symptoms. However, no research has been conducted on the intergenerational transmission of attachment insecurities and the effect of the self-amplifying cycle among former prisoners of war (ex-POWs) and their offspring attachment insecurities. Objective: This research aims to explore the intergenerational impact of a self-amplifying cycle of PTSD and attachment insecurities among ex-POWs on their offspring's attachment orientations. Method: We sampled dyads of Israeli ex-POWs of the Yom Kippur war and their adult offspring (ex-POW group) (n = 80) as well as dyads of Israeli veterans who fought in the Yom Kippur war, but were never held captive, and their adult offspring (control group) (n = 40). Veterans reported on PTSD severity and attachment orientations (anxiety, avoidance). Offspring reported on attachment orientations. We conducted (a) hierarchical regressions to predict offspring attachment orientations as a function of veterans' attachment orientations, and (b) moderated mediation analyses examining the role of veterans' PTSD in the intergenerational transmission of attachment orientations. Results: Ex-POWs' attachment anxiety was associated with offspring's reports of higher attachment anxiety and avoidance, and this intergenerational transmission of attachment was mediated by ex-POWs' PTSD severity. These effects were not significant in the control group. Conclusions: Decades after the war end, the intergenerational sequelae of war captivity are evident by the impact of the self-amplifying cycle of PTSD and attachment insecurities among ex-POWs and their offspring's attachment insecurities. Therefore, it is imperative for clinicians to recognize the intergenerational transmission and to focus not only on the trauma but also on the traumatized person's attachment injuries and the shattering of core beliefs about the world, self, and others, in the context of attachment-based therapies.

Anxiety Buffer Disruption: Relationship Threat, Death Anxiety, and Coping Appraisals Among Low and High Posttraumatic Stress Symptom Samples

Objective: Prior work suggests that people function effectively in the world, in part, by relying on sociocultural anxiety-buffer systems to protect against death anxiety. However, traumatic experiences may overwhelm and disrupt those systems, and this work tests whether posttraumatic stress symptoms reflect a vulnerability to death anxiety and risk of coping failure.

Method: Following posttraumatic stress screening (n = 4129), individuals with low (n = 187) and high (n = 186) posttraumatic stress symptoms engaged in either an anxiety-buffer stressor task (contemplating relationship problems) or control task. Participants subsequently reported death anxiety and made coping appraisals.

Results: Results supported four key hypotheses. Among individuals with low posttraumatic stress: (1) death anxiety was low under control conditions but moderately increased after contemplating relationship problems; and (2) perceived coping ability remained high in both conditions. However, among those with high posttraumatic stress: (3) death anxiety was exceptionally high in both the relationship problems prime and the control conditions—indicating anxiety buffer disruption; and (4) perceived coping ability was low in the control condition, and even lower after contemplating relationship problems.

Conclusions: These findings support the hypotheses and make novel contributions, in that prior research on the existential implications of PTSD have not considered that anxiety buffer disruption may be associated with failure to cope with new challenges after traumatic experiences. Future research should determine whether therapies can improve the core dimensions of functional worldviews, a sense of meaning and self-esteem, and whether such improvements result in improvements to perceived coping abilities.

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.

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.

Research domain criteria and the study of trauma in children: Implications for assessment and treatment research

By definition, the Diagnostic and Statistical Manual (DSM) diagnosis of posttraumatic stress disorder (PTSD) requires exposure to a traumatic event. Yet, the DSM diagnostic requirements for children and adolescents for PTSD may fail to capture traumatized youth with significant distress and functional impairment. Many important studies have utilized PTSD diagnosis as a mechanism for grouping individuals for comparative studies examining brain functioning, neuroendocrinology, genetics, attachment, and cognition; however, focusing only on those with the diagnosis of PTSD can miss the spectrum of symptoms and difficulties that impact children who experience trauma and subsequent impairment. Some studying child trauma have focused on examining brain and biology of those with exposure and potential impairment rather than only those with PTSD. This line of inquiry, complementary to PTSD specific studies, has aided our understanding of some of the changes in brain structure and neuroregulatory systems at different developmental periods following traumatic exposure. Application of the Research Domain Criteria (RDoC) framework proposed by NIMH to the study of child trauma exposure and subsequent impairment is an opportunity to examine domains of function and how they are impacted by trauma. Research to date has focused largely in the areas of negative valence, regulatory, and cognitive systems, however those studying complex or developmental trauma have identified an array of domains that are impacted which map onto many of the RDoC categories. This paper will review the relevant literature associated with child trauma as it relates to the RDoC domains, outline areas of needed research, and describe their implications for treatment and the advancement of the field.

Military and Premilitary Trauma, Attachment Orientations, and Posttraumatic Stress Disorder Severity Among Male and Female Veterans

Samples in prior studies examining attachment theory in the military have been predominantly composed of male combat veterans. Given the rates of sexual trauma among female veterans and differences in the association between attachment and posttraumatic stress disorder (PTSD) severity for sexual trauma survivors, it was necessary to consider the attachment characteristics of veterans within a mixed-sex sample. Participants were a mixed-sex veteran sample seeking inpatient trauma-related treatment (N = 469). Using independent samples t tests, we examined sex differences in attachment. Consistent with our hypothesis, women reported a higher level of attachment anxiety than did men, t(351) = -2.12, p = .034. Women also reported a higher level of attachment avoidance, t(351) = -2.44, p = .015. Using hierarchical regression, we examined the contribution of attachment anxiety and avoidance to PTSD severity, partialing out variance accounted for by demographic variables and traumatic experiences. Consistent with our hypotheses, attachment avoidance predicted PTSD severity on the Clinician-Administered PTSD Scale for DSM-IV (CAPS), β = .20, p < .001, and the PTSD Checklist-Civilian Version (PCL-C), β = .18, p < .001. Attachment anxiety did not predict CAPS severity but did predict PCL-C severity, β = .11, p = .020. These results suggest the association between attachment avoidance and PTSD is not exclusive to combat trauma and may apply more generally to the larger veteran population. Higher levels of attachment anxiety and avoidance among female veterans potentially implicate the presence of greater attachment fearfulness among this particular subpopulation of veterans.

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.

Secondary Traumatization in Caregivers Working With Women and Children Who Suffered Extreme Violence by the "Islamic State"

Introduction: Refugees fleeing persecution, torture, or sexual violence are at high risk of developing both acute and chronic psychological disorders. Systematic violence, as committed against the Yazidi minority in Northern Iraq by the terror organization known as the Islamic State (IS), can be seen as a particularly traumatic burden to the victims, but also to caregivers providing treatments and assistance to them. The intense exposure to traumatic content may cause secondary traumatization in respective caregivers. This study aims (1) to identify the prevalence of secondary traumatization in caregivers working with traumatized women and children from Northern Iraq; (2) to determine the specific distressing factors and resources of the caregivers; as well as (3) to analyze whether caregivers' personal history of trauma or flight, attachment styles, working arrangements as well as support offers qualify as risk or resilience factors for secondary traumatization. Materials and Methods: In this cross-sectional study, N = 84 caregivers (social workers, psychotherapists/physicians, and interpreters) in the context of a Humanitarian Admission Program (HAP) for women and children traumatized by the so called IS were investigated about their work-related burdens and resources. Secondary traumatization was assessed with the Questionnaire for Secondary Traumatization (FST). To identify relevant determinants for secondary traumatization multiple linear regression analyses were performed. Results: Secondary traumatization was present in 22.9% of the participating caregivers, with 8.6% showing a severe symptom load. A personal history of traumatic experiences, a personal history of flight, a higher number of hours per week working in direct contact with refugees as well as a preoccupied attachment style were detected as risk factors for secondary traumatization. A secure attachment style could be identified as a resilience factor for secondary traumatization. Discussion: Caregivers working with traumatized refugees are at high risk of developing secondary traumatization. Based on the findings of this study and theoretical considerations, a framework of classification for different types of trauma-associated psychological burdens of caregivers working with traumatized refugees is proposed. Implications for the training and supervision of professionals in refugee- and trauma-care are discussed.

Dispositional mindfulness mediates the relationships of parental attachment to posttraumatic stress disorder and academic burnout in adolescents following the Yancheng tornado

Background: Previous studies have shown that parental attachment is associated with low severity of posttraumatic stress disorder (PTSD) and low academic burnout in individuals who have experienced traumatic events. Objective: The present study investigated the ways in which parental attachment is related to PTSD symptoms and academic burnout in Chinese traumatized adolescents by considering the role of dispositional mindfulness. Method: A total of 443 Chinese adolescents who had experienced a severe tornado one year prior to this study completed measures of parental attachment, dispositional mindfulness, PTSD and academic burnout. Results: The results showed that our model fitted the data well [χ²/df = 2.968, CFI = 0.971, TLI = 0.955, RMSEA (90% CI) = 0.067 (0.052-0.082)] and revealed that dispositional mindfulness partially mediates the relationship between parental attachment, PTSD severity and academic burnout. Conclusions: The findings suggested that dispositional mindfulness and parental attachment may be two critical resources in dealing with traumatization and academic burnout.

Associations between adverse childhood experiences, student-teacher relationships, and non-medical use of prescription medications among adolescents

OBJECTIVE

Few studies have investigated associations between adverse childhood experiences (ACE) and nonmedical use of prescription medication (NMUPM) in population-based samples of adolescents, and even fewer have examined whether promotive factors might buffer these effects. The present study assesses the direct effects of ACE and positive student-teacher relationships on NUMPD and whether positive student-teacher relationships moderate this association.

DESIGN

Data were from the 2013 Minnesota Student Survey (MSS), an in-school survey administered every three years to students throughout Minnesota. The analytic sample (n=104,332) was comprised of 8th, 9th, and 11th graders.

RESULTS

Approximately 3% of students acknowledged past year NMUPM, the majority of whom reported at least one ACE. The most frequently used prescription drug was Ritalin/ADHD medications (1.71%) followed by opiate-based painkillers (1.67%), tranquilizers (0.92%), and stimulants (0.75%). Students who reported any use tended to use more than one medication. For every additional ACE, there was a 56%, 51%, 47%, and 52% increase in the odds of past year stimulant use, ADHD medication, pain reliever, and tranquilizer use, respectively. The estimated rate of the number of prescription drugs used increased by 62% for every additional ACE. Positive student- teacher relationships buffered the association between ACE and NMUPD, especially at higher levels of ACEs.

CONCLUSION

Our findings have important implications for prevention work. Training educators to recognize trauma symptomology and cultivating strong student-teacher relationships are important considerations for future school-based substance use prevention initiatives.

Can the dissociative PTSD subtype be identified across two distinct trauma samples meeting caseness for PTSD?

INTRODUCTION

For over a century, the occurrence of dissociative symptoms in connection to traumatic exposure has been acknowledged in the scientific literature. Recently, the importance of dissociation has also been recognized in the long-term traumatic response within the DSM-5 nomenclature. Several studies have confirmed the existence of the dissociative posttraumatic stress disorder (PTSD) subtype. However, there is a lack of studies investigating latent profiles of PTSD solely in victims with PTSD.

PURPOSE AND METHOD

This study investigates the possible presence of PTSD subtypes using latent class analysis (LCA) across two distinct trauma samples meeting caseness for DSM-5 PTSD based on self-reports (N = 787). Moreover, we assessed if a number of risk factors resulted in an increased probability of membership in a dissociative compared with a non-dissociative PTSD class.

RESULTS

The results of LCA revealed a two-class solution with two highly symptomatic classes: a dissociative class and a non-dissociative class across both samples. Increased emotion-focused coping increased the probability of individuals being grouped into the dissociative class across both samples. Social support reduced the probability of individuals being grouped into the dissociative class but only in the victims of motor vehicle accidents (MVAs) suffering from whiplash.

CONCLUSIONS

The results are discussed in light of their clinical implications and suggest that the dissociative subtype can be identified in victims of incest and victims of MVA suffering from whiplash meeting caseness for DSM-5 PTSD.

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.

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.

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.

A Qualitative Exploration of the Use of Attachment Theory in Adult Psychological Therapy

There is a growing interest into how attachment theory can inform psychotherapeutic practice with adults. This study aimed to explore how a group of therapists with an interest in attachment theory use it in their work with adult clients. A cross-sectional qualitative design was adopted. Sampling, data collection and analysis procedures were guided by grounded theory principles. Semi-structured telephone interviews were conducted with 12 therapists from a variety of training backgrounds. Data were coded and developed into thematic categories. Six primary themes were identified to describe how attachment theory influenced the clinical practice of the sample through the following: (i) complementing other therapeutic models; (ii) providing a framework to understand the development of clients' mental health problems; (iii) working with different attachment styles; (iv) thinking about the therapeutic relationship as an attachment relationship; (iv) influencing the different stages of the therapeutic process; and (vi) influencing clinical service design and delivery. It is concluded that attachment theory can play a significant role in influencing the practice of therapists and can be usefully adopted to complement therapeutic processes irrespective of the therapist's dominant clinical orientation. Further research is needed to explore the views of clinicians from different theoretical orientations and to investigate the security of the client-therapist attachment within the context of therapeutic change processes.

KEY PRACTITIONER MESSAGE

Attachment theory may have implications for practice across a range of different types of therapy and may help therapists to bridge apparent differences between modality-specific formulation and techniques. Attachment theory can be used to understand the development of mental health problems. Therapists should assess and formulate clients' attachment styles, and these formulations should guide therapeutic approaches. Attachment theory provides a comprehensive framework for facilitating the therapist's attentiveness to relational issues and use of the therapeutic relationship as a fulcrum for change. The principles of attachment theory can be used to inform all stages of the therapeutic process, as well as the design and delivery of mental health services.

Somatic Complaints and Attachment in Former Prisoners of War: A Longitudinal Study

OBJECTIVE

War captivity includes a unique constellation of simultaneous somatic and interpersonal assaults. This raises questions about the link between attachment and somatic complaints among ex-prisoners of war (ex-POWs). Although the attachment literature assumes that attachment affects somatic complaints and not vice versa, to date no empirical studies assess the association between the two variables over time. In this article we prospectively examine the association between attachment and somatic complaints over time among ex-POWs and comparable veterans.

METHOD

The current study included two groups of male Israeli veterans of the 1973 Yom Kippur War: ex-POWs and comparable veterans who were not taken captive. Both groups were assessed via self-report measures at three times: T1 (1991), T2 (2003), and T3 (2008)--18, 30, and 35 years after the war, respectively.

RESULTS

Ex-POWs reported higher levels of somatic complaints and attachment insecurities. These levels increased over time compared to combatant veterans. Moreover, while there was a unidirectional influence of somatic complaints on attachment security over time among combatant veterans, this relationship was bidirectional among ex-POWs.

CONCLUSIONS

The present study suggests that the combined physical and interpersonal assaults experienced during captivity have adverse effects on combatants and on attachment security, even three decades later. More important, in ex-POWs the relationship between these domains appears to be interactive and mutual, with one reinforcing the other, and vice versa.

Associations between specific psychotic symptoms and specific childhood adversities are mediated by attachment styles: an analysis of the National Comorbidity Survey

Accumulated evidence over the past decade consistently demonstrates a relationship between childhood adversity and psychosis in adulthood. There is some evidence of specific associations between childhood sexual abuse and hallucinations, and between insecure attachment and paranoia. Data from the National Comorbidity Survey were used in assessing whether current attachment styles influenced the association between adverse childhood experiences and psychotic symptoms in adulthood. Hallucinations and paranoid beliefs were differentially associated with sexual abuse (rape and sexual molestation) and neglect, respectively. Sexual abuse and neglect were also associated with depression. The relationship between neglect and paranoid beliefs was fully mediated via anxious and avoidant attachment. The relationship between sexual molestation and hallucinations was independent of attachment style. The relationship between rape and hallucinations was partially mediated via anxious attachment; however this effect was no longer present when depression was included as a mediating variable. The findings highlight the importance of addressing and understanding childhood experiences within the context of current attachment styles in clinical interventions for patients with psychosis.

Mother-infant attachment and the intergenerational transmission of posttraumatic stress disorder

Evidence for the intergenerational transmission of posttraumatic stress disorder (PTSD) is documented in the literature, although the underlying mechanisms are poorly understood. Attachment theory provides a framework for elucidating the ways in which maternal PTSD may increase offspring PTSD vulnerability. The current study utilized two independent prospective data sets to test the hypotheses that (a) maternal PTSD increases the probability of developing an insecure mother-infant attachment relationship and (b) an insecure mother-infant attachment relationship increases the risk of developing PTSD following trauma exposure in later life. In the first study of urban, primarily low-income ethnic/racial minority mothers and infants (N = 45 dyads), elevated maternal PTSD symptoms at 6 months were associated with increased risk for an insecure, particularly disorganized, mother-infant attachment relationship at 13 months. In the second birth cohort of urban, low-income mothers and children (N = 96 dyads), insecure (avoidant or resistant) attachment in infancy was associated in a dose-response manner with increased lifetime risk for a diagnosis of PTSD by adolescence. A history of disorganized attachment in infancy predicted severity of PTSD symptoms, including reexperiencing, avoidance, hyperarousal, and total symptoms, at 17.5 years. In both studies, associations between attachment and PTSD were not attributable to numerous co-occurring risk factors. The findings suggest that promoting positive mother-child relationships in early development, particularly in populations at high risk for trauma exposure, may reduce the incidence of PTSD.

Parents bereaved by infant death: PTSD symptoms up to 18 years after the loss

OBJECTIVE

Losing an infant or fetus late in pregnancy, during birth or in the first year of life is a potentially traumatic event for parents. However, little is known about the factors contributing to chronic posttraumatic stress reactions in this population. The present study examined chronic posttraumatic stress disorder (PTSD) symptoms and potential correlates in 634 mothers and fathers up to 18 years (M=3.4 years) after the death of their infant.

METHODS

Members of a private national support organization for parents bereaved by infant death were contacted and asked to participate in the study. Participants filled out a questionnaire package including measures of PTSD (the Harvard Trauma Questionnaire), coping (the Coping Style Questionnaire), perceived social support (the Crisis Support Scale) and attachment (the Revised Adult Attachment Scale). Associations between variables were examined through the use of analyses of variance, correlation analyses and a regression analysis.

RESULTS

We found an estimated PTSD prevalence of 12.3%. Type of loss (pre-, peri- or postnatal) did not have any effect on PTSD severity, but lower gestational age was associated with more symptoms. Time since the loss, female sex, attachment avoidance, attachment anxiety, emotion-focused coping, rational coping, feeling let down and social support satisfaction accounted for 42% of the variance in PTSD severity.

CONCLUSIONS

The study highlights the long-term impact of infant loss and points to attachment, coping and social support as important contributors to the development and maintenance of posttraumatic stress symptoms.

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.

The Missing Link between Juvenile Delinquency and Pediatric Posttraumatic Stress Disorder: An Attachment Theory Lens

The present paper reviews pediatric posttraumatic stress disorder, emphasizing the relational basis of the disorder and highlighting the missing link between juvenile delinquency and trauma. The first part of the paper defines trauma and the diagnostic criteria for PTSD, noting child-specific features. The second part reviews the literature emphasizing the relational and attachment relevant nature of trauma. The third part explores psychological mechanisms for how attachment relations could affect trauma responses. Attachment relations (1) shape core schemas of the world, others, and the self and (2) foster emotional engagement or disengagement, both of which have been associated with traumatic responses. The most empirically supported pediatric trauma treatment, trauma-focused cognitive behavioral therapy (TF-CBT), acknowledges the attachment figure's influence and includes treating and training the parent and conjoint child-parent discussion. The next section reviews the noteworthy link between juvenile delinquency and trauma history. More awareness of trauma and PTSD in children and adolescents is recommended to effectively address juvenile delinquency. The review ends with a few helpful points for practicing pediatricians regarding childhood trauma.

Insecure attachment is an independent correlate of objective sleep disturbances in military veterans

BACKGROUND

Sleep disturbances and interpersonal problems are highly prevalent in military veterans with post-traumatic stress disorder (PTSD) and are associated with substantial comorbidities and increased healthcare costs. This study examines the association between interpersonal attachment styles and sleep in a high-risk cohort of military veterans with PTSD symptoms.

METHODS

Participants were 49 military veterans (85% male) enrolled in a treatment study of combat-related sleep disturbances. Data were collected at pre-treatment baseline. Attachment anxiety and avoidance, clinical characteristics, and subjective sleep quality were characterised via self-report. Polysomnographic sleep measures were averaged from two nights of in-laboratory sleep studies and included: visually scored duration and continuity, the percentage of stage 3+4 sleep and rapid eye movement (REM) sleep, and quantitative electroencephalographic (QEEG) measures of delta and beta power during NREM and REM sleep. Linear regressions evaluated the relationship between attachment styles and sleep with adjustment for demographics, and PTSD and depressive symptoms.

RESULTS

Greater attachment anxiety was associated with reduced percentage of stage 3+4 sleep, (β=-0.36, p<0.05) and increased relative beta power during NREM sleep (β=0.40, p<0.05). By contrast, greater attachment avoidance was positively associated with delta power during NREM and REM sleep (β=0.35 and 0.38, respectively, p<0.05).

CONCLUSIONS

These findings suggest specific effects of interpersonal styles on physiological sleep measures. Elucidating both the neurobiological and psychological correlates of PTSD-related sleep disturbances is critical for developing future targeted intervention efforts aimed at reducing the burden of PTSD.

The relationship between chronic whiplash-associated disorder and post-traumatic stress: attachment-anxiety may be a vulnerability factor

BACKGROUND

In more than 90% of whiplash accidents a good explanation regarding the association between trauma mechanism, organic pathology, and persistent symptoms has failed to be provided.

OBJECTIVE

We predicted that the severity of chronic whiplash-associated disorder (WAD), measured as number of whiplash symptoms, pain duration, pain-related disability, and degree of somatisation would be associated with the number of post-traumatic stress disorder symptoms (PTSD). Secondly, we expected attachment-anxiety to be a vulnerability factor in relation to both PTSD and WAD.

DESIGN

Data were collected from 1,349 women and 360 men suffering from WAD from the Danish Society for Polio, Traffic, and Accident Victims. The PTSD symptoms were measured by the Harvard Trauma Questionnaire. All three core PTSD clusters were included: re-experiencing, avoidance, and hyperarousal. Attachment security was measured along the two dimensions, attachment-anxiety and attachment-avoidance, by the Revised Adult Attachment Scale.

RESULTS

PTSD symptoms were significantly related to the severity of WAD. In particular, the PTSD clusters of avoidance and hyperarousal were associated with the number of whiplash symptoms, disability, and somatisation. Attachment-anxiety was significantly related to PTSD symptoms and somatisation but not to pain and disability. A co-morbidity of 38.8% was found between the PTSD diagnosis and WAD, and about 20% of the sample could be characterised as securely attached.

CONCLUSIONS

The PTSD clusters of avoidance and hyperarousal were significantly associated with severity of WAD. The study emphasises the importance of assessing PTSD symptomatology after whiplash injury. Furthermore, it highlights that attachment theory may facilitate the understanding of why some people are more prone to develop PTSD and WAD than others.

Alexithymia and posttraumatic stress: subscales and symptom clusters

This study examined the relationship between the emotion-regulating factor alexithymia and the occurrence of posttraumatic stress disorder (PTSD) after critical incidents in a nonclinical sample of 136 nurses and ambulance personnel working in military facilities. The results showed that alexythima accounts for variance in PTSD symptoms. Breaking PTSD into its 4 symptom clusters, alexithymia was found to predict numbing and hyperarousal symptoms but not avoidance or reexperiencing symptoms. Finally, the rarely investigated, but clinically relevant, distinctive subdimensions of alexithymia were examined in relation to the 4 PTSD clusters. The difficulty identifying feelings subscale contributed most to the numbing and hyperarousal PTSD subscales. Clinical implications and future research directions are discussed.

Attachment style in the prediction of recovery following group treatment of combat veterans with post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) can be difficult to treat, with gains often particularly modest in combat veterans. Although group-based treatments are commonly delivered for veterans, little is known about factors influencing their outcomes. Attachment style is known to be associated with psychopathology after trauma and is critical to group-based interventions, but has not yet been investigated in relation to treatment outcome. A better understanding of factors that influence outcome is critical in optimizing the effectiveness of such interventions. This study investigated attachment style as a predictor of outcome for 103 veterans attending group-based treatment for combat-related PTSD. Measures included the Clinician Administered PTSD Scale, PTSD Checklist, and Relationship Styles Questionnaire. Path analyses indicated preoccupied attachment style strongly negatively predicted outcome following treatment. The preoccupied attachment style impedes recovery in group-based treatment for veterans with PTSD. Potential mechanisms underlying this finding are discussed. The results suggest that greater attention should be paid at initial assessment to attachment style of veterans before entering PTSD treatment, particularly group-based interventions.

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.