Loneliness and Childhood Maltreatment May Be Related With Avoidant Attachment in Persistent Depressive Disorder

Rear view of boy on bed at hospital ward. Lonely male patient is sitting in front of window. He is wearing blue gown.
Inpatients with persistent depressive disorder were recruited at a German University Hospital for a 10-week inpatient treatment with the Cognitive Behavioral Analysis System of Psychotherapy.

In persistent depressive disorder (PDD), avoidant attachment may explain the link between loneliness and childhood maltreatment (CM), according to results of a study published in the Journal of Affective Disorders.

Inpatients (n=60) with PDD were recruited at the Ludwig-Maximilians University Hospital Munich, Germany for a 10-week inpatient treatment with the Cognitive Behavioral Analysis System of Psychotherapy. Gender- and age-matched controls (n=60) were recruited through social media. In this analysis, responses to a questionnaire about CM, attachment, and loneliness were compared between inpatients and controls.

The PDD and control cohorts were aged mean 40.4 (SD, 11.9) and 40.2 (SD, 11.7) years, respectively. The patients reported higher scores on the Childhood Trauma Questionnaire (CTQ; t, -3.79; P <.001), the UCLA Loneliness Scale (UCLA; t, -3.53; P <.001), the Relationship Scales Questionnaire (RSQ) subscale anxiety (RSQ-Anx; t, -2.88; P =.003), and the RSQ subscale avoidance (RSQ-Avo; t, -1.78; P =.038) instruments.

Among the PDD cohort, CTQ, UCLA, RSQ-Anx, and RSQ-Avo scores were significantly correlated (all P ≤.05). For the controls, RSQ-Anx scores were not correlated with CTQ or RSQ-Avo scores.

In a mediation analysis, CM predicted avoidant attachment (β, 0.014; P <.001) and anxious attachment (β, 0.016; P =.009) and loneliness was predicted by avoidant attachment (β, 0.579; P <.001) and anxious attachment (β, 0.156; P =.028). There was also an indirect relationship between CM and loneliness through avoidant attachment (β, 0.008).

In a moderated mediation analysis, the relationship between CM and loneliness mediated by avoidance was significant in both the PDD (β, 0.008) and controls (β, 0.008), indicating no group effect.

The major limitation of this study was that questionnaire responses may have been affected by memory, social desirability, and response biases.

The study authors concluded, “Our study yields new insights into psychological mechanisms underlying PDD, ie, CM, attachment representation, and loneliness. All constructs examined are present to a greater degree in patients with PDD compared to nonclinical individuals. Additionally, an avoidant attachment style might mediate the association between CM and loneliness.”

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Sabaβ L, Buchenrieder N, Rek SV, et al. Attachment mediates the link between childhood maltreatment and loneliness in persistent depressive disorder. J Affect Disord. 2022;312:61-68. doi:10.1016/j.jad.2022.06.021