Research News: PTSD, Attachment and Healing

Leutze_1851_WashCrossDelaware The number of suicides reported by the Army has risen to the highest level since record-keeping began three decades ago. Last year, there were 192 among active-duty soldiers and soldiers on inactive reserve status, twice as many as in 2003, when the war began. (Five more suspected suicides are still being investigated.) This year’s figure is likely to be even higher: from January to mid-July, 129 suicides were confirmed or suspected, more than the number of American soldiers who died in combat during the same period. The New York Times

What Is PTSD?

Posttraumatic stress disorder (PTSD) can occur after the trauma of experiencing or witnessing  threatened or actual death or serious injury, or other serious threat to the physical integrity of self or others, such as assault. This type of trauma is usually accompanied by intense fear, helplessness, or horror at the time of the event. Symptoms of reliving the trauma and avoiding any reminder of it often create significant distress and negatively affect the individual’s  interpersonal and occupational functioning. In the acute phase, PTSD symptoms can last up to three months after the event. When the symptoms persist longer, PTSD is said to be chronic. Often, symptoms do not begin immediately and they can be delayed for six months or more after the event. When inadequately treated, PTSD can have fatal consequences such as homicide and suicide.

Who Is Affected?

It is estimated[i] that 50%–90% of all people are exposed to at least one serious traumatic event during their lifetimes. However, only about 6%-8% develop PTSD and a third of those suffer a severe form of the condition.

What Are the Causes?

The mechanism by which some individuals are vulnerable to PTSD and not others has been variously hypothesized. The most prominent theories are:

  1. The biological model
    Information about external stimuli and their assessment is processed by the amygdala. Traumatic stressors produce an emotional reaction of fight, flight or freeze and significant increases in stress hormones. The hippocampus and medial prefrontal cortex mediate the final response of the individual in trying to cope with the traumatic event. This theory suggests that posttraumatic stress disorder occurs when there is a failure to regulate the activity of the amygdala, which results in hyper-reactivity to threat (what is often referred to as the amygdala hijack).
  2. The early childhood experiences model
    Most researchers have found that childhood trauma, chronic adversity, and family stressors increase the risk for PTSD in adulthood.
  3. The traumatic memory model 
    A theory that has gained prominence in recent years, it distinguishes between memories that are easily recalled and are associated with emotions related to the trauma and repressed memories that cannot be deliberately accessed and are associated with typical PTSD symptoms such as nightmares and flashbacks.
How Is It Treated?

Most treatments for PTSD consist of techniques that expose the individuals to imagined re-experiencing of the trauma under safe therapeutic conditions, an approach that dates back to the treatment of World War II veterans. This type of treatment includes extensive emotional processing and narrative reconstruction of traumatic events in psychotherapy session, and may also include daily home review of audiotaped sessions.

Other efficacious treatments are cognitive behavioral psychotherapy and eye movement desensitization and reprocessing (EMDR). These treatments also induce patients to consciously review (and thus reprocess) painful details of their traumatic experience in a therapeutically safe environment.

PTSD and Childhood Attachment

A recent study[ii] by Columbia and Cornell researchers suggests that childhood attachment problems may play a crucial role in the development of adult PTSD and that exposure treatment may not be the sole important treatment mechanism.

According to attachment theory, secure and insecure childhood attachment to the primary caregiver (most often the mother) has important consequences for adult functioning and psychopathology. The theory, developed by British psychologist, psychiatrist and psychoanalyst John Bolwby, suggested that the innate human drive to form attachments that elicit protective, caretaking behaviors from adults is a crucial aspect of healthy infant development. When the caregivers are available and responsive, the infant develops a secure attachment “base” that facilitates the child’s exploration of the world and relationships. When the caregivers are absent or uncaring, an insecure attachment style results, with consequences for adult self-esteem, perceived safety and interpersonal functioning.

There is significant research evidence to support the underlying premise that secure individuals are better equipped to deal with the consequences of trauma and with stress and anxiety in general. A study[iii] of children aged 18 months to five years whose mothers had anxiety disorders showed that 65% had inhibited interpersonal behaviors and 35% did not. Of those who did, 80% had a history that suggested insecure maternal attachments. Another study[iv] of 172 mothers with anxiety disorders and their infant children over a number of years found that  anxious/resistant attachment assessed in infancy was a reliable predictor of anxiety disorders in adolescence.

In reference to PTSD, secure attachment would appear to bolster the individual’s ability to recover from serious trauma and return to previously healthy level of functioning. Insecure attachment would appear to undermine the individual’s ability to risk “exposure” to trauma reminders and the confidence to make use of available interpersonal support to overcome the effects of trauma.

Treating PTSD by Improving Interpersonal Factors

It appears therefore that prolonged exposure therapies, cognitive psychotherapy, medication and EMDR may neglect to adequately address interpersonal factors in PTSD, including the critical but under-recognized role of social support as both protective after the trauma and as a mechanism of recovery.

Given the potential importance of early childhood attachment in the development of healthy  interpersonal relationships, it would appear that assessing the individual’s early life experiences and taking therapeutic steps to address self-esteem, perceived safety and interpersonal functioning may be necessary for a truly complete and lasting recovery from PTSD.


[i]Bisson, J. I. (2007). Post-traumatic stress disorder. BMJ, 334(7597), 789-793. doi: 10.1136/bmj.39162.538553.80
[ii]Markowitz, J. C., Milrod, B., Bleiberg, K., & Marshall, R. D. (2009). Interpersonal Factors in Understanding and Treating Posttraumatic Stress Disorder. J Psychiatr Pract, 15(2), 133-140. doi: 10.1097/01.pra.0000348366.34419.28.
[iii]Manassis K, Bradley S, Goldberg S, et al. Behavioral inhibition, attachment and anxiety in children of mothers with anxiety disorders. Can J Psychiatry 1995;40:87–91.[PubMed: 7788623].
[iv]Warren SL, Huston L, Egeland B, et al. Child and adolescent anxiety disorders and early attachment.JAACAP 1997;36:637–644.