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

https://doi.org/10.1016/j.cpr.2022.102228Get rights and content

Highlights

  • Current models of PTSD neglect the role of attachment processes.

  • Deficits in attachment security play a critical role in enhancing stress responses and are associated with PTSD.

  • Promoting attachment security can buffer the effects of trauma and stress in people with secure attachment systems.

  • Integrating attachment factors into biological and cognitive models of PTSD may augment the capacity they can modulate PTSD.

  • Boosting attachment security may improve treatment response for PTSD by harnessing the benefits of attachment processes.

Abstract

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.

Introduction

Our understanding of posttraumatic stress disorder (PTSD) has been guided over the past 40 years by models that have emphasized biological, learning, or cognitive processes. Despite the enormous advances made by these models, their dominance has resulted in a relative neglect of how social processes can impact psychological adjustment to traumatic experiences. This is a remarkable omission because traumatic stress often occurs within a social context, especially mass disasters and interpersonal trauma. It is also interesting that social processes have been largely neglected considering that seminal theories regarding attachment processes are rooted in how people navigate threats, and in this sense are central to understanding traumatic stress.

This review provides an overview of attachment theory as it pertains to traumatic stress. It reviews the extant literature on preclinical research on attachments and stress response. It then provides a critique of naturalistic and clinical studies that have mapped how attachment availability can moderate traumatic stress. This review provides an integration of attachment theory and findings with prevailing models of PTSD, and proposes that fuller appreciation of social processes can augment the explanatory value and clinical utilities of these models.

Section snippets

Biological models

Prior to reviewing social processes, it is important to consider the prevailing models of PTSD to understand how social factors may be integrated into these models. Arguably the most influential models of PTSD have involved biological and learning mechanisms that typically invoke fear conditioning principles. Specifically, in response to a traumatic event two key stress systems are engaged. One of these is the fast-acting autonomic nervous system, which implicates the sympathetic response that

Attachment theory

One of the key theories pertinent to social processes in the wake of trauma is attachment theory. Sixty years ago Bowlby articulated the key role that social attachments can play a central role in response to threat (Bowlby, 1961). This theory posits that humans, as well as many other species, possess a hard-wired tendency to turn to others in the face of adversity because from an evolutionary perspective this increases the chances of survival (Bowlby, 1969). Attachment theory proposes that

The role of attachments on adaptation to stress

Inherent in attachment theory is the notion that how a person responds to a traumatic event will largely depend on the extent to which they can benefit from mental representations of a secure attachment base that promotes a sense of safety and security (Mikulincer, Shaver, & Solomon, 2015). The model of attachment theory, as outlined by Mikulincer and Shaver (2016), involves a two-stage process. The first stage involves the detection of threat, which leads to a preconscious activation of the

Evidence of social attachments to reduce biological stress responses

Attachment security during the early years can contribute to physiological responses to stress, including the parasympathetic response (Groh & Narayan, 2019). Respiratory sinus arrythmia (RSA) is one key index of parasympathetic response, and studies indicate that maltreated children have lower resting RSA, and abused children have greater RSA reactivity during parent-child interactions than their non-abused counterparts (Skowron et al., 2011). Further, longitudinal studies suggest that

Recognising the social context of traumatic stress

One of the major reasons to emphasise the role of social factors in PTSD is that much trauma occurs within a social context. Most salient examples are major disasters, such as earthquakes and hurricanes, as well as war and humanitarian crises. These events can impact on entire communities, and even nations; these impacts can involve disruptions to infrastructure, housing, community systems, and other social institutions that can undermine social networks. Social connectedness can be critical

Integrating social processes with key models of PTSD

This review highlights that attachment factors play an important role in the etiology, maintenance, and remission of PTSD. The question remains as to how social processes should be integrated into existing models of PTSD. The evidence suggests that social processes should not be considered separate from, but rather integral to, biological and cognitive models. Figure 1 provides a schematic of how social factors can be contextualised into prevailing conceptualisations of PTSD. Specifically, on

Clinical implications

The demonstrated impacts of social factors on traumatic stress has implications for prevention and treatment of PTSD. In terms of prevention, the accumulating evidence on how proximity with attachment figures can ameliorate stress responses points to the potential for social-based initiatives in the wake of trauma to reduce PTSD. For example, following mass disasters, when social networks are often disrupted (Hobfoll et al., 2007), mobilising social supports and facilitating engagement with

Concluding comment

This review indicates that there are convergent lines of evidence attesting to the strong protective role that social processes can play in assisting many people to adapt to a traumatic event. The understanding of PTSD has grown enormously as a result of biological and cognitive models, yet these models can be further advanced by integrating social mechanisms into these models. Social processes should be regarded as key to both the biological and cognitive perspectives rather than a separate

Declaration of Competing Interest

None

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