ReviewAttachment processes in posttraumatic stress disorder: A review of mechanisms to advance theories and treatments
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
References (208)
- et al.
Activating attachment memories affects default mode network in a non-clinical sample with perceived dysfunctional parenting: An EEG functional connectivity study
Behavioural Brain Research
(2019) - et al.
The role of adult attachment style, birth intervention and support in posttraumatic stress after childbirth: A prospective study
Journal of Affective Disorders
(2014) - et al.
Therapeutic alliance as a mediator of change: A systematic review and evaluation of research
Clinical Psychology Review
(2020) Respiratory sinus arrhythmia: A transdiagnostic biomarker of emotion dysregulation and psychopathology
Current Opinions in Psychology
(2015)- et al.
Attachment-related attention bias plays a causal role in trust in maternal support
Journal of Experimental Child Psychology
(2019) - et al.
Activating attachment representations during memory retrieval modulates intrusive traumatic memories
Consciousness and Cognition
(2017) - et al.
Thinking of attachments reduces noradrenergic stress response
Psychoneuroendocrinology
(2015) - et al.
Neural evidence for a multifaceted model of attachment security
International Journal of Psychophysiology
(2013) - et al.
Hurricane Katrina and youth anxiety: The role of perceived attachment beliefs and parenting behaviors
Journal of Anxiety Disorders
(2009) - et al.
A multi-modal approach to the study of attachment-related distress
Biological Psychology
(2010)