131

Psychology and Psychotherapy: Theory, Research and Practice (2019), 92, 131–147
© 2018 The British Psychological Society
www.wileyonlinelibrary.com

The links between adult attachment and

post-traumatic stress: A systematic review
Natalie Barazzone1* , Ines Santos2, John McGowan1 and
Eloise Donaghay-Spire1
1
Canterbury Christ Church University, East Sussex, UK
2
Sussex Partnership NHS Foundation Trust, Brighton, UK
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 moder-
ating 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.

*Correspondence should be addressed to Natalie Barazzone, Canterbury Christ Church University, Salomons Centre, 1 Meadow
Rd, Tunbridge Wells TN1 2YG, UK (email: nbarazzone@gmail.com).

DOI:10.1111/papt.12181
132 Natalie Barazzone et al.

The links between attachment, trauma, and post-traumatic stress

Attachment theory
Attachment theory describes the interaction between an infant and their caregiver,
whereby proximity to the caregiver provides a base from which exploration in the world
can be negotiated. This affiliative bond allows the infant to seek safety in times of need and
provides the means to alleviate and regulate distress (Bowlby, 1988). Attachment
relationships are fundamentally important for our survival and well-being (Bowlby, 1969).
Early relationship patterns are internalized and influence associated expectations,
attitudes, and beliefs towards future experiences, as well as the capacity to regulate
emotions (Bowlby, 1980).
Bartholomew and colleagues developed a model of adult attachments, proposing that
attachment can be viewed in terms of models of the self and others based on a dimension
of dependency and avoidance (Bartholomew, 1990; Fraley & Shaver, 2000). This is
illustrated by a four-category, two-dimensional model, consisting of secure, dismissing,
preoccupied, and fearful attachments (Bartholomew, 1990) that sit along dimensions of
anxiety and avoidance (Brennan, Clark, & Shaver, 1998; see Table 1). Attachment anxiety
refers to a fear of rejection in relationships, whereas attachment avoidance refers to a fear
and evasion of closeness and intimacy. Attachment strategies reflect these dimensions,
which either consist of insistent proximity seeking or of avoidance in relationships
(Mikulincer, Shaver, & Horesh, 2006).
Attachment theory has become an increasingly important framework for understand-
ing relationships and psychological distress in both clinical practice and research. There
has been increasing interest in how attachment may influence the development of post-
traumatic stress (PTS; de Zulueta, 2006). Mikulincer et al. (2006) argued: ‘the mental
health implications of attachment-system functioning are highly pertinent to understand-
ing a person’s psychological reactions to traumatic events’ (p. 8).
Post-traumatic stress symptoms can result from exposure to or threat of death, actual
or serious injury, or sexual violence (directly or indirectly). They are characterized by
intrusions, avoidance, negative alterations in cognitions, mood, arousal, and reactivity
following a traumatic event (American Psychiatric Association; APA, 2013). While post-
traumatic stress disorder (PTSD) is clearly defined, the underlying mechanisms of PTS are
less clear. Information-processing principles have been incorporated into behavioural and
cognitive models, viewing PTS symptoms in terms of unprocessed trauma memories
(Brewin & Holmes, 2003). Evidence-based treatments for PTSD include trauma-focused
cognitive behavioural therapy and eye movement desensitization and reprocessing
therapy, both of which are based on information-processing theories. While these
interventions may consider the influence of early relational experiences, they do not
explicitly take account of attachment security in either formulation or treatment
protocols.

Theoretical links between attachment and PTS symptoms

There is developing interest in how an individual’s attachment style may play a role in
precipitating, perpetuating, and protecting against PTS (Bonanno, 2004). Interpersonal
difficulty is an associated feature of PTSD (APA, 2013), that is, often the ability to trust and
be close to others tends to be compromised (Mills & Turnball, 2004). The concept of
attachment is likely an important consideration in assessing the quality of relationships,
 Attachment and post-traumatic stress 133

Table 1. Four-category model of attachment (Bartholomew, 1990; Brennan et al., 1998)

Positive Model-of-Self Negative Model-of-Self

(Low anxiety) (High anxiety)

Positive Model-of-Other

(Low avoidance) SECURE PREOCCUPIED

Comfortable within Anxious and ambivalent in

intimacy & autonomy and relationships

trust in relationships

Negative Model-of-Other DISMISSING FEARFUL

(High avoidance)

Dismissing of intimacy Fearful of intimacy

Exhibit a distorted sense of Exhibits avoidance but may

self-reliance also seek proximity in

relationships.

one’s ability to draw on or effectively use social support, as well as any tendencies to
withdraw from relationships (Bartholomew, 1990).
A secure attachment is believed to increase resilience and protect individuals from
the negative effects of trauma (Bonanno, 2004). Mikulincer et al. (2006) considered
the reciprocal relationship between attachment and PTS, suggesting that trauma is
likely to activate the attachment system. This may lead an individual to seek out an
external or internalized attachment figure for protection and to reduce harm
associated with the traumatic experience. They also suggest that differences in
attachment strategies determine PTS severity and influence how it is experienced and
expressed, specifically the frequency of intrusions and avoidance behaviours. In a
recent review, Mikulincer, Shaver, and Solomon (2015) further examined the
relationship between attachment and PTS with a particular focus on combat-related
trauma. This review concluded that attachment insecurities are related to PTS severity
134 Natalie Barazzone et al.

and offered hypotheses for the mechanisms underlying this relationship. The authors
suggest that insistent proximity-seeking attempts displayed in anxiously attached
individuals may impair the regulation of emotion required to manage trauma. Avoidant
strategies that are associated with a distorted sense of self-reliance and the suppression
of emotions may result in distress being unresolved (Mikulincer et al., 2006). It is also
likely that attachment security may have restorative effects following trauma and that
PTS symptoms could erode attachment security through disrupting the regulatory
functions of attachment.
A recent meta-analysis synthesized research to investigate the relationship between
adult attachment orientation and PTS symptoms (Woodhouse, Ayers, & Field, 2015). Its
findings indicated a medium association between secure attachment and reduced PTS
symptom severity, and a medium association between insecure attachment and higher
PTS symptom severity. A fearful attachment style, followed by an anxious attachment
style, was found to have the strongest association with PTS symptoms. Overall, dismissing
attachment was not significantly related to PTS. A noteworthy finding was that the
association between attachment and PTS symptoms was moderated by the type of PTSD
measure used, with self-report measures demonstrating a stronger relationship with PTS
symptoms compared to interview measures of PTSD.

Review aims
The current review aims to build on these findings by exploring whether the relationship
between attachment and PTS varies according to the nature of trauma endured. It
specifically seeks to address the following:
(1) What does current evidence tell us about the relationship between attachment and
PTS?
(2) Does the nature of this relationship differ according to the nature of trauma
experienced?
(3) What are the implications of these findings for future research and clinical practice?

Methodology
Literature search strategy
Electronic searches were conducted using PsycINFO, Medline, the Cochrane Library
databases, and Google Scholar from inception to August 2017. Search terms were entered
and combined to identify relevant literature. These included the following: (1)
‘attachment’, (2) ‘PTS’, or (3) ‘PTSD’. Titles and abstracts of relevant studies were
examined to refine relevant papers, consistent with the review aims. Searches were
limited to peer-reviewed journals and papers published in English.
The following exclusion criteria applied during the selection stage:
(1) Participants under the age of 18 years;
(2) Studies with a predominant focus on disorders other than PTS;
(3) No PTS measure reported;
(4) Treatment studies;
(5) No adult attachment measure reported;
(6) Secondary PTS;
(7) Studies that do not distinguish between type of trauma.
 Attachment and post-traumatic stress 135

Search results
Twenty-one studies met the inclusion criteria. Figure 1 outlines the literature search
process according to PRISMA.

Literature review
Childhood abuse
Alexander (1993) investigated the long-term effects of child sexual abuse (CSA) in a
community-based sample of 112 women. After controlling for the characteristics of CSA
(e.g., age of onset, type of abuse, degree of coercion, relationship with perpetrator), it was
Identification

Records identified through database

searching (PsycINFO, Medline, the
Cochrane Library, Google Scholar)
Limits: English language, peer-
reviewed, adults (n = 728)

Records after duplicates removed (n = 710)

Screening

Records excluded:

Records screened (n = 710) (n = 652)

Eligibility

Full-text articles assessed for eligibility (n = 58) Full-text articles excluded:

Under 18: 2
No PTSD measure: 8
Not predominant focus of
PTSD: 4
No attachment measure: 5
Secondary Trauma: 1
Articles included in the review (n = Traumas undifferentiated: 2
Included

21) Treatment studies: 9

Not empirical: 4
Unavailable: 1
(n = 36)

Figure 1. PRISMA diagram for MBI literature search. [Colour figure can be viewed at wileyonlineli-
brary.com]
136 Natalie Barazzone et al.

found that attachment security was a significant predictor of the avoidance component of
PTS, but not intrusions. Secure attachment, as measured by the Relationship Question-
naire (RQ; Bartholomew & Horowitz, 1991), was the most significant predictor of
avoidance. Characteristics of CSA were better predictors of intrusions as compared to
attachment security. Attachment was a better predictor of personality characteristics than
PTS symptoms. In contrast, in Roche, Runtz, and Hunter’s (1999) study involving a female
undergraduate sample (N = 307), CSA did not predict symptoms of PTS when attachment
was controlled for. This study used the Trauma Symptom Inventory (TSI; Briere, 1995),
which assesses a broader range of symptom domains related to trauma compares to PTS
measures in other studies reviewed. Attachment anxiety, measured by the Relationship
Scales Questionnaire (RSQ; Griffin & Bartholomew, 1994), was found to be associated
with more of the TSI subscales than attachment avoidance. They found that attachment
style mediated the relationship between CSA- and trauma-related symptoms in adulthood,
indicating that attachment may be an underlying causal mechanism of PTS.
Aspelmeier, Elliott, and Smith (2007) explored the relationship between CSA and
symptoms of PTS in a large sample of female college undergraduates (N = 324). They
compared students who had experienced CSA with a group who had not. Attachment was
measured using the RQ and the Inventory of Parent and Peer Attachment (Armsden &
Greenberg, 1987). CSA accounted for 13% of the variance in PTS symptoms, 10% of which
was accounted for by attachment style with a medium effect size (Cohen, 1992). More
participants with a CSA history reported insecure attachment styles than those from the
non-CSA group. Findings demonstrated that a dismissing attachment style was unrelated
to PTS symptoms. The authors tentatively suggested that a reluctance to express emotions
may explain this lack of association. This study indicates that secure attachment may be a
buffer against negative CSA outcomes, although it is not possible to determine the
direction of causation.
Stovall-McClough and Cloitre (2006) explored the prevalence of ‘unresolved attach-
ments’ assessed by the Adult Attachment Interview (AAI; George, Kaplan, & Main, 1985)
in an ethnically diverse sample of 60 women reporting histories of physical and sexual
abuse. The AAI is a standardized interview that explores individuals’ autobiographical
memories of past attachment relationships. Attachment classification is based on the
degree of coherence of memory, thought, and discourse regarding attachment relation-
ships, as well as the resolution surrounding traumatic experiences. Participants’ states of
mind are classified as secure (F), dismissing (Ds), preoccupied (E), or unresolved
regarding trauma or loss (U). An unresolved attachment classification refers to high levels
of incoherence and poor metacognitive monitoring of discourse. Findings indicated that
57% were classified with an ‘unresolved’ attachment style and 45% of the women were
unresolved regarding abuse (Utr). The Utr participants were 7.5 times more likely to
warrant a PTS diagnosis than those without Utr, regardless of education and age. Those
with Utr were significantly more likely to be diagnosed with PTSD compared to those with
dismissing and secure states of mind but not preoccupied states of mind; however, further
analyses indicated that Utr status continued to significantly predict PTSD status over and
above preoccupied status.
Sandberg (2010) investigated the relationship of attachment styles to victimization,
PTS symptoms, and dissociation. In the sample of college women (N = 199) using the RQ
measure of attachment, it was demonstrated that secure attachment was negatively
correlated with PTS. Consistent with Aspelmeier et al.’s (2007) findings, there was no
correlation between dismissing attachment and PTS. However, it is worth noting that
dismissing attachment moderated the relationship between trauma and PTS. Contrary to
 Attachment and post-traumatic stress 137

Stovall-McClough and Cloitre’s (2006) findings, preoccupied attachment was positively

correlated with PTS symptoms. Attachment did not mediate the relationship between
trauma and PTS as found in Roche et al.’s (1999) study. Nevertheless, analyses revealed a
moderating effect of attachment on the relationship between trauma and PTS, accounting
for up to 20% of the variance.

War- and combat-related trauma

Mikulincer, Florian, and Weller (1993) examined the responses of 140 undergraduates
exposed to Iraqi missile attacks on Israel during the Gulf War. Participant responses were
examined in relation to attachment styles, severity of PTS symptoms, and their area of
residence (dangerous vs. less dangerous). Attachment orientation was assessed using a 15-
item measure developed by Mikulincer and Erev (1991) based on Hazan and Shaver (1987)
conceptualization of how adults feel in close relationships. Self-reporting data revealed
that individuals with a preoccupied attachment reported higher levels of emotion-focused
coping, depression, and anxiety, in addition to the most severe PTS symptoms. Dismissing
individuals appeared to express distress through higher somatization and avoidance-
related PTS symptoms. Consistent with the theoretical conceptualization of dismissing
attachment, the authors suggested that these participants may have suppressed their
emotional distress and instead expressed it through physical ailments. The effects found
were more pronounced for those individuals who were exposed to more danger.
Solomon, Ginzburg, Mikulincer, Neria, and Ohry (1998) explored the relationship
between attachment style and the psychological well-being amongst 164 ex-prisoners of
war (PoW) and 184 matched controls (non-PoW). Attachment was measured using
Mikulincer and Erev’s (1991) measure of attachment. PoW veterans with insecure
attachment styles reported more severe PTS symptoms than those with a secure
attachment style. Those with a preoccupied attachment style reported more severe PTS
symptoms than those with a dismissing attachment style. Veterans with a secure
attachment style demonstrated the best adjustment. Interestingly, attachment style did
not predict PTS symptoms for non-PoWs. This may support the theory that attachment
behaviours tend to be activated by extreme stress (Mikulincer et al., 2006). It is also
consistent with the finding that traumatic experiences such as being held captive, which
are likely to involve an interpersonal component (e.g., through torture, humiliation), are
more closely related to insecure attachment (Muller, Thornback, & Bedi, 2012). As this
study relied on self-report and memory of events occurring 18 years after the war, the data
may be subject to recall error and biases. It is also possible that additional traumatic life
events during these 18 years (which were not assessed) may have had a bearing on the
psychological well-being of participants. Nevertheless, the matched comparison group
enriches and strengthens the findings.
Dieperink, Leskela, Thuras, and Engdahl (2001) examined the relationship between
attachment style, severity of trauma, and PTS symptoms amongst 107 veterans who had
been PoW. Using both the RQ and the experiences in close relationships (ECR; Brennan
et al., 1998), they found that 65% of the veterans had an insecure attachment style and
42% of this group met the criteria for PTSD. Of those who reported a secure attachment,
10.8% met the criteria for PTSD. Consistent with Sandberg’s (2010) findings, attachment
insecurity was the strongest predictor for PTS (independent of trauma severity),
accounting for 21.4% of the variance in symptoms. The authors did not differentiate
between the individual insecure attachment styles, so it was not possible to detect
differences in terms of their associations with PTS symptoms.
138 Natalie Barazzone et al.

Zakin, Solomon, and Neria (2003) compared attachment in Israeli male PoW veterans
(n = 164) to a control group of non-PoW veterans (n = 189). Secure attachment style,
assessed using Mikulincer and Erev (1991) measure of attachment, and the personality
trait ‘hardiness’ were associated with fewer PTS symptoms in both PoW and non-PoW.
Hardiness predicted a greater amount of variance in PTS symptoms than attachment for
both groups, although it is important to consider that the data were collected almost
20 years after the war. Neither attachment nor hardiness was a significant moderating
factor in the relationship between trauma and PTS.
Kanninen, Punamaki, and Quouta (2003) findings challenged the view that a secure
attachment is a protective factor for developing PTS in a study of 176 former male political
prisoners. Using the AAI, they revealed that men with secure attachments were more
vulnerable to developing PTS symptoms than ‘preoccupied’ men following exposure to
psychological torture. A dismissing attachment, however, was more protective in the case
of psychological torture. In the case of physical torture, secure attachment was protective,
whereas men with preoccupied and dismissing attachments were more vulnerable to PTS
symptoms. With regard to symptomatology, both dismissing and preoccupied attach-
ments were associated with elevated intrusive symptoms, and dismissing attachment was
associated with elevated psychosomatic symptoms.
Mikulincer, Ein-Dor, Solomon, and Shaver (2011) built on Solomon et al.’s (1998)
study findings to examine attachment insecurity and PTS symptoms in the same group of
Israeli veterans at a later time point. Comparing PoW veterans (n = 156) with non-PoW
veterans (n = 163), ex-PoWs demonstrated greater attachment insecurity than non-PoWs
at 18, 30, and 35 years after the war. Attachment anxiety and avoidance increased for PoW
veterans over the 17-year period, whereas it decreased for non-PoWs. It was suggested
that the interpersonal and psychological effects of being held captive were likely to have
damaged individuals’ trust in the motives of others (Kanninen et al., 2003) and
consequently impacted on their attachment relationships. With regard to the impact of
PTS on attachment security, it was found that higher levels of PTS symptoms across each
time point following the war predicted higher attachment anxiety and avoidance in both
PoWs and non-PoWs. This study provides a unique longitudinal perspective, demon-
strating the mutual influence between attachment styles and PTS symptoms.
Escolas et al. (2012)’s findings indicated that in military personnel (N = 561), securely
attached individuals reported the least PTS symptoms. This was followed by dismissing,
preoccupied, and fearful attachment styles, of which individuals reported the most PTS
symptoms. Differences in the level of association with PTS between attachments styles as
measured by the ECR were all significant apart from between dismissing and preoccupied.
The authors claim that securely attached military personnel may experience less stress as a
result of using social coping mechanisms and seeking help, although there was no
evidence to substantiate this hypothesis. Ferraj~ao and Oliveira (2015) explored the
mediating effects of attachment anxiety and attachment avoidance on PTS symptoms in a
sample of male veterans (N = 60) using the ECR measure of attachment. Veterans who
had recovered from PTS had lower attachment anxiety compared to veterans experienc-
ing chronic PTS. Attachment anxiety was a partial mediator of the effect of combat
exposure on PTS symptoms, whereas attachment avoidance was not.
In a longitudinal study spanning 24 years, Franz et al. (2014) examined the mediating
relationship between attachment insecurity on PTS symptoms amongst 975 ex-veterans
in Vietnam using the ECR measure of attachment. This study demonstrated a reciprocal
relationship between PTS symptoms and attachments to intimate others. PTS symptoms
in early life predicted both attachment anxiety and avoidance, and PTS symptoms in later
 Attachment and post-traumatic stress 139

life. Midlife attachment anxiety and avoidance mediated the relationship between early-
and later-life PTS symptoms. Mediation analyses demonstrated that attachment avoidance
and anxiety during midlife mediated PTS symptoms in later life. This study highlights that
attachment insecurity plays an important role in maintaining PTS symptoms and vice
versa. It was hypothesized that symptoms may impact on attachment relationships
through the influence of emotional responses in relationships, and likewise, the lack of
feelings of safety in a relationship may affect individuals’ resilience to manage stress.
Zerach and Tam (2016) conducted a cross-sectional study to examine the relationship
between attachment security (measured by the ECR) and PTS. They assessed a group of
young adults (n = 102) who had been evicted from their homes in Gaza (known as evicted
residents, ER), and who had also actively participated in resistance activity. Both
relocation and resistance entailed loss – such as family member, and witnessing violence.
They compared this group to evicted non-residents (ENR; n = 27) and non-evicted non-
residents (NENR; n = 53). Both attachment avoidance and attachment anxiety were
positively related to PTS symptoms. ER participants reported higher levels of attachment
anxiety and PTS symptoms compared to NENR participants. They found that type of
group (ER vs. NENR) moderated the relationship between attachment anxiety and PTS
symptoms, with the ER group reporting higher levels of PTS and attachment anxiety. The
authors explain this finding in terms of the possible impact of loss and uncertainty for
those in the ER group, particularly over an extended period of time and during the crucial
developmental stage of young adulthood.

Terrorist attack
Fraley, Fazzari, Bonanno, and Dekel (2006) investigated attachment security and
psychological adjustment of witnesses to the 9/11 World Trade Centre attacks
(N = 45). The study specifically explored participants’ psychological adjustment prior
to the attack, in addition to the long-term psychological impact of the attack. Participants’
attachment style was assessed using the RSQ. No main effects of attachment on PTS
symptoms were found. Preoccupied and dismissing individuals reported the highest level
of PTS, whereas fearful individuals reported comparatively lower PTS. Securely attached
individuals reported the least PTS symptoms. Friends and relatives of individuals with
preoccupied and fearful attachments were reported by others to be poorly adjusted
following the attacks, whereas friends of those with dismissing attachments reported no
change.

Loss
Christiansen, Olff, and Elklit (2014) cross-sectional study explored the relationship
between PTS symptoms and attachment insecurity in 361 mothers and 273 fathers who
had lost an infant in late pregnancy, during birth, or the first year of life. Attachment
orientation was measured using the Revised Adult Attachment Scale (RAAS; Collins,
1996). Findings revealed that mothers reported increased PTS symptoms and attachment
anxiety compared to fathers. The association between attachment insecurity, emotion-
focused coping, and PTS symptoms severity was greater in mothers; however, when these
variables and the time since their bereavement were entered into a regression model, both
attachment anxiety and avoidance were positively associated with PTS severity in the case
of both sexes.
140 Natalie Barazzone et al.

Multiple traumas
O’Connor and Elklit’s (2008) findings highlighted the protective nature of secure
attachment in the context of a range of traumatic experiences, including physical
violence, CSA, childhood physical abuse, and bereavement. In a sample of 328 students,
secure attachment, measured by the RAAS, was significantly associated with low levels of
current and lifetime PTS symptoms. Secure attachment was associated with the lowest
PTS symptoms, followed by preoccupied attachment and dismissive attachment. Fearful
attachment was associated with the highest PTS symptoms, whereas dismissive
attachment was strongly associated with negative affect and somatization.
Sandberg, Suess, and Heaton (2010), using an ethnically diverse sample of 224 women,
examined a wide range of traumatic life events in relation to attachment, including natural
disasters, military combat, and interpersonal traumas. Both attachment anxiety and
avoidance, assessed using the ECR, correlated positively with PTS. Attachment anxiety
mediated the relationship between intimate partner violence and adult sexual victimiza-
tion and PTS symptoms, but not for non-interpersonal types of trauma. Although the study
used a relatively large sample, recruiting from college settings may limit the generaliz-
ability of findings to clinical populations. Further, attachment anxiety was only a partial
mediating factor. Other variables, such as emotion regulation, cognitions, and coping
behaviours, may also influence this relationship.
Muller et al. (2012) examined the mediating role of attachment between CSA and
PTS symptoms amongst 803 university students (87% female). Attachment style was
measured using the RSQ. In addition to CSA, this was the first study to assess different
types of abuse both simultaneously and independently. Analyses demonstrated that
insecure attachment partially mediated the relationships between childhood psycho-
logical abuse, physical abuse, exposure to family violence, and PTS symptoms. When
different types of trauma were entered into a multiple regression model, the effects of
physical abuse and exposure to family violence on attachment were not significant,
suggesting that the psychological abuse had the most profound effect on individuals’
attachment security.
Huang, Chen, Su, and Kung (2017) study also highlights the difference between the
impact of interpersonal traumas versus non-interpersonal traumas on attachment anxiety
relative to attachment avoidance in a university sample (N = 162). Using the RAAS,
increased attachment anxiety was observed in individuals exposed to interpersonal
traumas. The interpersonal trauma group reported greater PTS symptoms than the non-
interpersonal trauma group. After controlling for age, occurrence of trauma and distress of
trauma, participants’ attachment anxiety (but not attachment avoidance), predicted
increased PTS severity in the interpersonal trauma group. The findings indicated that
attachment anxiety is central to interpersonal traumas and may explain why interpersonal
trauma exposure causes greater PTS symptoms.

Discussion
Relationship between attachment and PTS
Consistent with existing reviews (Mikulincer et al., 2015; Woodhouse et al., 2015), this
paper found that an insecure attachment appears to increase vulnerability for developing
PTS symptoms. Attachment has demonstrated mediating (Muller et al., 2012; Roche
et al., 1999; Sandberg et al., 2010) and moderating influences (Kanninen et al., 2003;
Sandberg, 2010; Stovall-McClough & Cloitre, 2006) on the relationship between
 Attachment and post-traumatic stress 141

attachment and PTS, and the type of trauma appears to be an important factor within this
relationship. Interpersonal trauma appears more highly associated with attachments
insecurity than non-interpersonal trauma (Aspelmeier et al., 2007; Huang et al., 2017;
Mikulincer et al., 2011; Muller et al., 2012; Solomon et al., 1998).
Attachment orientation also appears to be an important factor. Consistent with
Woodhouse et al.’s (2015) meta-analysis, individuals having a fearful or ‘unresolved’
attachment tended to fare worse in terms of PTS symptom severity in comparison
with other attachment styles (e.g., Escolas et al., 2012; O’Connor & Elklit, 2008;
Stovall-McClough & Cloitre, 2006). Similarly, on the dimensions of attachment anxiety
and attachment avoidance, studies demonstrated that participants reporting greater
attachment anxiety compared to attachment avoidance tended to report higher levels
of PTS (e.g., Christiansen et al., 2014; Ferraj~ao & Oliveira, 2015; Mikulincer et al.,
1993, 2011; Roche et al., 1999; Solomon et al., 1998). This is consistent with the
theoretical view that individuals with anxious attachments may be more likely to
report distress as compared to individuals with a dismissing attachment (Mikulincer,
Shaver, & Pereg, 2003). It may also highlight the fact that such individuals may be
more inclined to be threat-focused in the context of trauma and attachment
relationships.
With the exception of secure attachment, having a dismissing attachment style
appeared to be the least associated with PTS (e.g., Solomon et al., 1998; Stovall-McClough
& Cloitre, 2006) and in some cases there was no significant association with PTS (e.g.,
Aspelmeier et al., 2007; Fraley et al., 2006). This is also in keeping with Woodhouse
et al.’s (2015) findings. This may reflect the tendency for individuals with a dismissing
attachment to under-report distress (Mikulincer & Shaver, 2007). One study indicated that
having a dismissing attachment style may even be protective in the case of captivity in the
context of war. Another hypothesis is that the lack of association between dismissing
attachment and PTS symptoms may not reflect a higher level of resilience but may instead
highlight limitations of PTS measures in capturing other effects of trauma, such as
somatization.

Secure attachment as a protective factor

A notable finding is the protective nature of secure attachment. All but one of the studies
reported an association between a secure attachment style and lower levels of PTS
symptoms. This is in line with existing literature reviews outlined above. The mechanisms
underlying the effect of a secure attachment are not entirely clear. One hypothesis is that
secure individuals may internalize positive experiences of comfort and responsiveness,
and can draw on these experiences during times of distress (Zakin et al., 2003). A secure
attachment may also provide individuals with internal resources to make use of support,
thereby increasing resilience following trauma.
It is worth noting that secure attachment may not always protect individuals from PTS.
Kanninen et al. (2003) demonstrated that, when subjected to severe captivity-related
trauma in the context of war, a secure attachment could actually increase individuals’ risk
of PTS symptoms. It is possible that the trauma may conflict with previously held beliefs
about the world being safe, rendering previous coping strategies ineffective. Individuals’
confidence in attachment figure’s protection and availability may also be reduced
(Mikulincer et al., 2006), which highlights the role of PTS symptoms in also impacting on
attachment security.
142 Natalie Barazzone et al.

General critique of research

The findings of this review should be considered in the light of a number of
methodological limitations in the studies reviewed. A major flaw in research in this field
is the cross-sectional nature of the designs, which make it difficult to determine the
direction of causal relationships. Similarly, an inherent difficulty in researching the impact
of trauma is that it is not always possible to ascertain attachment styles and psychiatric
morbidity pre-trauma. It is, therefore, unclear to what extent trauma has an impact on
attachment styles and vice versa. Furthermore, the majority of studies rely on self-report
measures of attachment security and PTS and retrospective data of traumatic events.
Memory and reporting biases may therefore bring into question how accurately
attachment styles and PTS are assessed.
Studies predominantly focused on singular types of trauma. It was not reported
whether individuals assessed as meeting the criteria for CSA met the criteria for other
traumatic events, which may have influenced attachment orientations and/or experi-
ences of PTS. Further, most of the studies under review are based on Western and
Caucasian samples. It is not clear to what extent ethnicity plays a role in the differences
amongst attachment style and PTS. There are also clear gender differences in terms of the
type of trauma studied. Men are over-represented for traumas associated with military
combat and robbery, while women are over-represented for victimization in clinical
research. This is likely to limit the generalizability of findings.

Clinical implications
The findings discussed in this review have important implications for the treatment for
PTS. Evidence-based treatments target cognitions, emotion regulation, and physical
symptoms of trauma; however, these interventions rarely acknowledge the role of
attachment. Regardless of treatment modality, consideration of attachment in formulation
of PTS is likely to inform treatment plans in addition to the interpersonal approach of the
therapist.
Research has begun to apply attachment theory to the understanding and treatment of
PTS symptoms (Pearlman & Courtois, 2005; Sandberg, 2010). Indeed, there is increasing
evidence to suggest that assessing and accounting for attachment style in therapy may
improve the chances of successful treatment (Meyer & Pilkonis, 2002). Bowlby (1988)
postulated that therapists provide clients with a ‘secure base’ from which to explore
distressing experiences. The therapeutic relationship enables clients to build a sense of
safety and trust, to challenge unhelpful beliefs of the self and others, and develop a
capacity for secure attachment. This in turn may help the client become better at
regulating emotions as well as enabling mentalization of his or her experiences (Fonagy,
Gergely, Jurist, & Target, 2002). This may be particularly important given the links
between attachment and PTS.
The type of trauma experienced also appears to be important in terms of an
individual’s security in attachment relationships. This review suggests that individuals
who have experienced an interpersonal trauma are more likely to have an insecure and
anxious attachment (e.g., Huang et al., 2017; Mikulincer et al., 2011; Muller et al., 2012;
Roche et al., 1999; Sandberg et al., 2010; Solomon et al., 1998).
Assessing attachment is likely to inform how distress is expressed: Individuals with a
preoccupied attachment style are more likely to experience elevated PTS symptoms,
whereas those with a dismissing attachment style tend to under-report symptoms and may
 Attachment and post-traumatic stress 143

be more likely to somatize. Beliefs and perceptions about the availability of social support
and the likelihood of seeking help appear to vary amongst different attachment styles.
A further advantage of assessment attachment is that it may help to guide formulation
in terms of possible factors maintaining PTS. The current review supports the view that
individuals with dismissing attachment tend to display more avoidant coping behaviours
whereas individuals with preoccupied attachment tend to display more emotion and
threat-focused coping behaviours (Mikulincer et al., 1993). Consideration of clients’
attachment strategies used under stress may similarly help to direct the treatment focus.
Finally, it may be fruitful to consider the impact of PTS symptoms on the quality of
clients’ attachment relationships. Enabling the client to make effective use of social
support in the context of a secure relationship is likely to improve outcomes in the long
term given the protective nature of secure attachment relationships.

Limitations of this review

There are a number of limitations that should be considered when drawing conclusions
from this review. An important consideration relates to drawing comparison across
studies that use different methodologies used to measure attachment. This concerns
(1) the method of assessment, (2) the focus of the attachment relationship, and (3) the
classification of attachment derived from the measure.
With regard to the method of assessments, studies either use self-report checklists
(e.g., RQ, RSQ, ECR, RAAS) or interview methods (i.e., the AAI). Self-report measures rely
on conscious appraisals of relationships, whereas an interview method involves complex
coding of transcripts to assess coherence of mind in relation to early attachment
relationships. The focus of the attachment relationships also differs amongst measures,
with the self-report measures focusing on current intimate relationships and the interview
method emphasizing early developmental relationships. While individuals’ attachment
security tends to be relatively stable, it is also the case that it can change across the lifespan
as a result of experiences and the dynamics within relationships (Mikulincer & Shaver,
2007).
The classification of attachment also differs depending on the theoretical basis of the
measure, that is, whether it is based on a dimensional or categorical model of attachment.
A number of studies reviewed assess attachment along the dimensions of anxiety and
avoidance (e.g., Alexander, 1993; Fraley et al., 2006; Roche et al., 1999). Other studies
adopt a categorical model of attachment to assess security according to secure, dismissing,
preoccupied, fearful ways of relating, and in the case of the AAI – unresolved regarding
trauma or loss (e.g., Kanninen et al., 2003; Sandberg, 2010; Stovall-McClough & Cloitre,
2006).
Together, these differences within methodologies of attachment measures limit the
extent to which comparisons can be drawn between studies. This issue was highlighted in
Woodhouse et al.’s (2015) meta-analysis, which concluded that the relationship between
attachment and PTS was moderated by the type of measure used. Indeed, this is consistent
with research suggesting that there is in fact minimal convergence in self-reported
attachment styles and AAI security (Roisman et al., 2007).

Implications for future research

There is some evidence to suggest that an insecure attachment style contributes to the
onset and maintenance of PTS symptoms; however, we are still far from identifying and
144 Natalie Barazzone et al.

understanding the underlying mechanisms of this relationship. Dieperink et al. (2001)

emphasize the importance of differentiating symptoms related to trauma from those
intrinsic to individuals’ attachment style. The next step is for research to establish the
extent to which related factors vary according to type and onset of trauma. Research has
begun to determine how different attachment styles affect the therapeutic outcome (e.g.,
Goldman & Anderson, 2007; Tasca, Taylor, Ritchie, & Balfour, 2004). This research should
be prioritized to inform treatment choices and optimize treatment outcomes.
This review indicates that attachment style may change as a result of severe trauma,
which has important implications for treatment studies. While Solomon et al. (1998)
found that trauma had negative effects on attachment, it is possible that treatment may
positively influence clients’ view of themselves, others and the world. Despite the
commonly held belief that attachment styles are relatively stable and enduring across a
lifespan (McConnell & Moss, 2011), there is evidence to suggest that therapy can facilitate
a shift from an insecure to a secure attachment style (e.g., Stovall-McClough & Cloitre,
2003; Travis, Bliwise, Binder, & Horne-Moyer, 2001; Wesselmann & Potter, 2009). This
research is still in its infancy, and further research is needed to identify differences across
therapeutic modalities, and incorporating client factors.
Further research should explore the overlap between attachment styles and PTS
symptoms, and specifically, how attachment and trauma may influence therapeutic
outcomes. This may be done by examining clients who have experienced different types
of traumas, with differing levels of complexity. Given that a large proportion of the current
research uses a student population, further research using clinical samples is warranted.

Conclusion
This systematic review builds on the recent reviews examining the relationship between
PTS and attachment and contributes to the development of a more unified theoretical
framework for attachment and PTS. There is little doubt that attachment and PTS share an
important relationship. It is therefore surprising that the theoretical frameworks of
attachment and PTS have tended to be relatively disparate. Limited research in this field
and inherent design limitations make this area of research a challenging one. Based on
evidence so far, replicating studies and overcoming research drawbacks will help further
our understanding of the important relationship between attachment and PTS.

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Received 16 February 2017; revised version received 28 February 2018