The process of developing healthy emotional relationships is a key factor in attaining happiness and improving quality of life. However, a significant proportion of the human population lacks the ability to connect with other individuals and form meaningful relationships. This condition is referred to as an attachment disorder. Although this condition usually develops in childhood, it can continue into adulthood if left unrecognized and unaddressed.

How Do Attachment Disorders Develop?

For more than 70 years, psychologists have recognized that the ability to form emotional relationships begins in early childhood. A healthy relationship between a child and their caregiver lays the foundation for healthy attachments throughout an individual’s life.  “If you come from a world with good attachments, you are more likely to go on to develop good attachments,” says psychotherapist Toby Ingham.[1] On the other hand, he says, “People who have gone through traumatic events in childhood often have problems with attachments.” As they have difficulty forming attachments, such individuals struggle to maintain close relationships and may have problems with commitment.

How do you identify patients who have disordered attachments? “These patients may come across as more vulnerable or isolated,” says Dr Ingham. Often, such patients are hesitant to open up to the healthcare professional and may appear hostile and aloof. Conversely, other patients may have extremes of emotions and bouts of impulsivity.


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The Far-Reaching Impact of Attachment Disorders

In adults, attachment disorders can do more than disrupt relationships. Several studies have linked attachment disorders to other physical, mental, and social problems.

  • Alexithymia:  This is a subclinical personality trait in which patients lack emotional awareness. Such patients find it difficult to identify, express, or even experience emotions. They may come across as being cold and distant, which increases their difficulty forming and maintaining relationships. Insecure attachment is believed to be a key etiologic factor in the development of alexithymia.2
  • Depression and anxiety: Patients with attachment disorders tend to internalize emotions, which makes them vulnerable to developing additional psychiatric problems.  Investigators who conducted a meta-analysis reported that preoccupied and unresolved attachment was found to have a significant association with depression.3 Researchers who conducted another study reported that insecure attachment, specifically attachment anxiety, was found to contribute to emotional dysregulation and an increase in symptoms of anxiety.4
  • Addiction:  Patients with attachment disorders are more likely to develop addictive habits. “Breakdown of attachment generally tends to go with addiction,” says Dr Ingham, adding that addiction could be one of the self-isolating responses to abnormal attachment. Indeed, authors of one study reported that increased alcohol consumption served as an emotional coping strategy for adults with attachment disorders and alexithymia.5
  • Eating disorders: There is a strong association between insecure attachment and various types of eating disorders, including anorexia, bulimia, and binge eating disorder.6 This is attributed to self-identity issues and self-blame.

Attachment Disorders May Have a Neuronal Basis

Research indicates that attachment disorders may be associated with changes that occur in the temporal lobes of the brain, specifically in the amygdala. The amygdala is concerned with the regulation of emotional learning, rewards, and memory. Studies have shown that disordered attachment during infancy has been associated with an increase in amygdala volumes in adulthood.7 Atypical amygdala connectivity in the resting state has also been documented in individuals with attachment disorder.8

This line of research has helped provide insight into the pathophysiology of attachment disorders. Currently, however, it does not contribute much to formulating treatment strategies, and it is not clear whether neuronal changes can influence treatment efficacy. “Detecting neuronal indicators for each individual patient is not as important as finding out about their developmental history,” says Dr Ingham. Understanding the context of the problems that people end up living with is more helpful in planning the course of treatment. “It is important that people understand that what they have gone through in childhood underlies why they have attachment problems in their adult life,” he adds.

What Is the Best Method for Managing Attachment Disorders?

Psychotherapy forms the cornerstone of treatment for attachment disorders in adults. However, as these patients often do not share their emotional experiences readily, traditional methods of psychoanalysis such as interpretation and confrontation may not be effective. “One needs to develop sensitivity and tact,” advises Dr Ingham. “It is important to remember that this set of patients lack ordinary communication and conversational skills. It would be easy for the analyst to say the wrong thing, which can make them close up even further.”

Instead, it may be useful to adopt more unique and focused forms of psychotherapy. Transference-focused psychotherapy, for example, has been found to improve attachment security and mentalizing capacity.9 By projecting their feelings for their caregivers onto the therapist, individuals are encouraged to express and explore their emotions more deeply.

Group psychotherapy is also an option for treating disordered attachments. The group often serves as a secure base for attachment and works on the principle of removing resistance to secure attachment rather than directly promoting secure attachment. The group leader acts as a “maturational agent,” encouraging the group to verbalize their feelings and foster emotional self-regulation. This process facilitates the developmental maturation that may have been hindered by their problems with attachment.10

In terms of whether there is a role for medication, “That depends whether there are specific problems that medication can help with,” says Dr Ingham. “Specific psychiatric conditions such as anxiety or depression may benefit from concurrent medication. If the patient shows signs of these conditions, it is best to get a proper diagnosis from a psychiatrist, who will prescribe appropriate medication.”  Medication cannot, of course, replace psychotherapy. For patients who have complex associated problems, careful treatment planning and coordination are needed.

Staying On Top of Attachment Disorders

An increasing number of patients are seeking professional treatment for attachment disorders. “Public interest in understanding attachment disorder is increasing,” says Dr Ingham. “This is an area which will continue to gather some interest and momentum; the future is quite bright.” Indeed, research is addressing previously unexplored areas related to this condition, such as the development of abnormal attachments resulting from parental distraction with mobile devices.11 Psychiatrists and psychologists need to stay up to date on the latest developments, not only for the benefit of current clients but also those future clients whose attachment disorders are the result of a very different set of circumstances.

References

1.     Ingham T. Attachment disorder in adults. October 6, 2018. Accessed August 3, 2020. https://www.tobyingham.com/attachment-disorder-in-adults/

2.     Schimmenti A, Caretti V. Attachment, trauma, and alexithymia. In Luminet O, Bagby R, Taylor G, eds. Alexithymia: Advances in Research, Theory, and Clinical Practice. Cambridge University; 2018;127-141.  

3.     Dagan O, Facompré CR, Bernard K. Adult attachment representations and depressive symptoms: a meta-analysis. J Affect Disord. 2018;236:274-290.

4.     Nielsen SK, Lønfeldt N, Wolitzky-Taylor KB, Hageman I, Vangkilde S, Daniel SI. Adult attachment style and anxiety – the mediating role of emotion regulation. J Affect Disord. 2017;218:253-259.

5.     Lyvers M, Mayer K, Needham K, Thorberg FA. Parental bonding, adult attachment, and theory of mind: a developmental model of alexithymia and alcohol‐related risk. J Clin Psychol. 2019;75(7):1288-1304.

6.     Faber A, Dubé L, Knäuper B. Attachment and eating: a meta-analytic review of the relevance of attachment for unhealthy and healthy eating behaviors in the general population. Appetite. 2018;123:410-438.

7.     Lyons-Ruth K, Pechtel P, Yoon SA, Anderson CM, Teicher MH. Disorganized attachment in infancy predicts greater amygdala volume in adulthood. Behav Brain Res. 2016;308:83-93.

8.     van Hoof MJ, Riem MM, Garrett AS, van der Wee NJ, van IJzendoorn MH, Vermeiren RR. Unresolved–disorganized attachment adjusted for a general psychopathology factor associated with atypical amygdala resting-state functional connectivity. Eur J Psychotraumatol. 2019;10(1):1583525.

9.     Levy KN, Draijer N, Kivity Y, Yeomans FE, Rosenstein LK. Transference-focused psychotherapy (TFP). Curr Treat Options Psychiatry.  2019;6(4):312-324.

10.  Black AE. Treating insecure attachment in group therapy: attachment theory meets modern psychoanalytic technique. Int J Group Psychother.  2019;69(3):259-286.

11.  McDaniel BT. Parent distraction with phones, reasons for use, and impacts on parenting and child outcomes: a review of the emerging research. Human Behav Emerg Tech. 2019;1(2):72-80.