This picks up where part 1 ended, I suggest starting with Informational Article: Attachment Theory (Pt 1) because we use concepts and vocabulary explained in the first section will be used during this section.
Attachment Disorders are in the Trauma-and Stressor-Related Disorders class in the DSM-V, this means that traumatic experiences have to be present for the disorder to form. This also means it is highly related to PTSD/CPTSD, Adjustment disorders and Acute stress disorder. Attachment disorders are diagnosed in children, similar issues in adults will be diagnosed differently should a diagnosis be given.
The two attachment disorders are Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED). They are very similar in the aetiology and treatment to the point that DSED used to be a subtype of RAD. The causes of these disorders are similar to that form insecure attachment styles. This is lack of attunement, child abuse, long term separation from the caregiver, inconsistent caregivers and exposure to other forms of trauma like community violence.
Attachment disorders can also form if a child has a mostly secure attachment but it is interrupted by a traumatic event, within age paraments. Attachment disorders, however, are not usually diagnosed in older children/adolescence and not adults acquired attachment issues from trauma will be clinically classed as PTSD or C-PTSD.
Populations at Risk For Attachment Disorders:
- Children living in poverty
- Children of parents who suffer from Addiction
- Children of parents who suffer from untreated mental health issues and/or trauma of their own
- Children who have a mother who is incarcerated
- Children who have experienced multiple traumatic events/Complex trauma
- Children who have had many different foster care providers
- Children who have repeated changes of primary caregivers
- Children who have spent time in an orphanage
- Children who lived in abusive family systems
- Children who suffered from neglect (Emotionally and/or materially)
- Children who were abused (emotionally/psychologically, physical, or sexual)
- Children who were taken away from a primary caretaker after forming a healthy bond
Non-Diagnostic Signs of Attachment Disorders:
- Abnormal elimination patterns (e.g., wetting, soiling, hoarding food)
- Anti-social behaviours (e.g., lying, stealing, manipulating, destructiveness, cruelty, fire-setting, aggression)
- Difficulties with learning and/or behaviour difficulties in school/daycare
- Fear and disconnection from their parents/caregivers
- Feeding and eating difficulties
- Indiscriminately seeks affection and/or comfort from strangers
- Lack of authenticity, spontaneity, flexibility, and expressed empathy
- Lack of physical affection and closeness and/or inappropriate clinginess
- Lack of positive relationships
- Poor eye contact, facial responses, body language and other non-verbal communication
- Can’t be soothed by others or self
- Problems with self-regulating and self-monitoring
Note: The DSM-V is an imperfect document and is always under discussion. There are always questions of diagnoses validity. Some believe attachment disorders are better understood under a Developmental Trauma Disorder (DTD) framework or in a Childhood C-PTSD framework.
DSM-5 Criteria for Reactive Attachment Disorder (RAD)
(American Psychiatric Association, 2013)
A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following
- The child rarely or minimally seeks comfort when distressed.
- The child rarely or minimally responds to comfort when distressed
B. A persistent social or emotional disturbance characterized by at least two of the following:
- Minimal social and emotional responsiveness to others
- Limited positive affect
- Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.
C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
- Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caring adults
- Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care)Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios)
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C).
E. The criteria are not met for autism spectrum disorder.
F. The disturbance is evident before the age of 5 years.
G. The child has a developmental age of at least nine months.
- Specify if Persistent: The disorder has been present for more than 12 months.
- Specify current severity: Reactive Attachment Disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.
Other Factors in RAD
Neglect is a factor in the development of RAD, so many children present with developmental delays and malnutrition. This disorder is more common in developmentally disabled infants because they are more likely than healthy children to be mistreated or institutionalized (Minnis et al, 2010)
Studies show 1.4 % of children living in an impoverished area in the United Kingdom had an attachment disorder. (Minnis et al, 2013) .4% of children in a danish study had RAD. (Skovgaard, 2010). However, Rates in certain populations are higher due to the nature of the disorder. 52% of juvenile offenders meet the criteria for RAD or similar attachment issues. (Moran et al, 2017). Those in foster care are also sen to have higher rates of RAD.
DSM-5 Criteria for Disinhibited Social Engagement Disorder (DSED)
(American Psychiatric Association, 2013)
A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:
- Reduced or absent reticence in approaching and interacting with unfamiliar adults.
- Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
- Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
- Willingness to go off with an unfamiliar adult with little or no hesitation.
B. The behaviors in Criterion A are not limited to impulsivity (as in Attention-Deficit/Hyperactivity Disorder) but include socially disinhibited behavior.
C. The child has exhibited a pattern of extremes of insufficient care as evidenced by at least one of the following:
- Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation and affection met by caregiving adults.
- Repeated changes of primary caregivers that limit ability to form stable attachments (e.g., frequent changes in foster care).
- Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios).
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).
E. The child has a developmental age of at least nine months.
- Specify if Persistent: The disorder has been present for more than 12 months.
- Specify current severity: Disinhibited Social Engagement Disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.
DSED Later In Life:
DSED puts children at risk for further harm due to the children with this disorder often engaging in behaviours like having no threat awareness and may easily be manipulated and abused by other people. Children will interact with strange adults who may wish harm to others, or get easily lost. (Oliveira, et al., 2012)
Little work into the long term effects of this disorder, some believing it is just grown out of. However, with the knowledge of the long term effects of RAD and other attachment issues, it needs further study.
More Info on DSED: Disinhibited Social Engagement Disorder (DSED): What It Is, Symptoms, & Treatments
CoMorbid Conditions in Attachment Disorders:
- 85% of the children had another psychiatric condition in addition to having an attachment disorder
- 52% had Attention Deficit Hyperactivity Disorder (ADHD)
- 29% had Oppositional Defiant Disorder (ODD)
- 29% had Conduct Disorder
- 19% had Post Traumatic Stress Disorder (PTSD)
- 14% had an Autism Spectrum Disorder (ASPD)
- 14% had a Specific Phobia
- 1% had a tic disorder like Tourette’s syndrome (Hong, et al., 2018)
Note: We have some issues with the DSM categories of ODD and Conduct disorder
Attachment & Trauma
Attachment is deeply important to understanding trauma in 5 major ways:
- Attachment formation influenced by trauma.
- Attachment as a risk & protective factor.
- Attachment’s influence on how we experience trauma.
- Attachment’s influence on other trauma linked disorders.
Trauma & Attachment Formation:
Trauma can form how we attach this is can be seen in that in maltreated children rates of disorganized attachment have been observed to be as high as 80% (Baer & Martinez 2006). Emotional neglect and abuse can factor in the two insecure organized types as well.
Attachment trauma is a framework of understanding the effects of cumulative developmental trauma in the early years of life. (Farina, Liotti, & Imperatori 2019). This shows that developmental trauma can define how you form your attachment and that this continuous into life, like all developmental trauma is.
This theory also shows how insecure attachment, especially disorganized is a form of trauma in and of itself. They are essentially intertwined for those of us with developmental trauma.
Attachment as A Risk & Protective Factor:
Early insecure attachment is a risk factor for suffering from psychological trauma and to participate in activities which put them at risk. One of the main patterns is continuing to be involved in unhealthy and sometimes abusive relationships.
Disorganized attachment has similar effects on the nervous system as C-PTSD. This leaves a child hypersensitized to stress in conjunction with the lack of coping skills they can not process later trauma. Because of the nature of attachment trauma, it is an interpersonal and complex trauma meaning later traumatic events are being layered on trauma for people with disorganized attachment. (Zulueta, 2009)
Anxious attachment is not a consistent protective or risk factor. Avoidant and disorganized attachment are risk factors for traumatization in conjunction with abuse. (Oconnor & Elklit 2008 59-71). Lack of secure attachment has been shown to predict higher levels of emotional distress after large events. Children of parents who developed PTSD after 9/11 suffered higher rates of emotional issues. (Chemtob, Nomura, & Abramovitz 2008).
Early secure attachment allows for protection from being involved in unhealthy relationships and participating in high-risk behaviour. Secure attachment can work to help prevent long term effects of trauma later in life.
It is considered a protective factor in the prevention of later psychological trauma (Oconnor & Elklit 2008 59-71). Secure attachment has been seen to be able to help prevent people from developing PTSD after events, this was seen in events like 9/11 (Fraley, Frazzari, Bonanno, & Dekel, 2006). Attachment overall is seen as a protective factor is that the long-term impacts of childhood trauma can be mediated by healthy early attachment experiences. (Styron & Janoff-Bulman 1997)
Processing trauma is shown to be easier for those with secure attachment. They are more willing to address trauma and have better recall of their memories. (Alexander, 1993). Proper processing and recall of memories allow the integration of trauma to occur at a faster rate and prevent severe flashbacks and body memories from lasting into the far future.
Attachment & The Expression of Trauma:
Disorganized attachment is connected with dissociation through it’s blocking of the ability to form a cohesive sense of self and the ability to perform any self-regulation or co-regulator experiences. This lack of regulation often leads to children falling back on the need to disconnect from the world. Attachment trauma itself generates dissociative symptoms common in Post Traumatic Stress Disorder (PTSD), Borderline Personality Disorder (BPD) and Dissociative Disorders. (Farina, Liotti, & Imperatori 2019).
Attachment with parents and peers is correlated with acts of bullying and being the victims of bullying (Nikiforou, Georgiou, & Stavrinides 2013). High attachment anxiety with fathers was shown to be the highest predictor for perpetrating bullying. Maternal avoidance/alienation along with attachment anxiety to father was shown to be a predictor of violence in females studied. Participants reporting higher anxiety about their maternal relationships were more likely to report being a victim of peer aggression in childhood. The victimization results were more prominent in females. (Williams, 2011)
Attachment & Other Trauma Linked Disorders:
Borderline Personality Disorder
Insecure attachment is highly connected with BPD, we can see commonalities in the cognitive distortions and emotional experiences of people with Anxious and disorganized attachment styles. 83-97% of people with BPD have an insecure attachment style. (Mosquera, Gonzalez, & Leeds 2014). Disorganized and anxious attachment styles were the most prominent types of attachment shown in BPD patients. In this study, the use terms fearful and unresolved based on the adult analysis terms. (Agrawal, Gunderson, Holmes, & Lyons-Ruth 2004)
Studies have shown that father-daughter and mother–son maltreatment and insecure attachment are predictors of symptoms related to BPD. (Godbout, Daspe, Runtz, Cyr, & Briere 2019)
This also connects to the way that BPD is considered by many to be a disorder of developmental and complex traumatic experiences. And that BPD is heavily tied to the three main axes of attachment, ability to form stable relationships, stable self-concept, and the ability to self and co regulate arousal.
Dissociative identity disorder (DID) & Other specified dissociative disorder (OSDD)
OSDD is a Secondary Structural Dissociative Disorder, along with C-PTSD & BPD. DID is a Tertiary Structural Dissociative disorder. To develop these both of these structural dissociative levels you have to experience disorganized attachment and early childhood trauma. Those with disorganized attachment lack self-regulation and often experience extreme confusion about who they and their caregivers are. These tendencies to fragment themselves will be compounded with other trauma, which will force the identity to not fuse and the fragmentation worsens.
Secondary does not cause fully differentiated parts and sometimes lack dissociation between parts. Sometimes the EPS experience a strong degree of differentiation having their own solidified identities but do not experience amnesia. Some might experience little differentiation but deal with dissociative amnesia between fragmented parts. Those with BPD and/or C-PTSD experience no differentiation and amnesia is not based fully around EPS if it is experienced.
Tertiary dissociation causes experiences of differentiated parts and amnesia between identities. The states of consciousness also experience multiple parts that are full identities on their own. The experiences of OSDD-1 might better fit under this label with the differentiation of parts closer to DID then BPD or C-PTSD.
Attachment to the positive portions of caregivers and split off the feelings of disconnection and insecure parts of attachment can be put within a separate part of consciousness in DID. This allows for feelings of love to exist without the fearful elements being overwhelmed. Insecurely attached parts might experience less confusion of attachment and not be stuck between responses and be protective. Attachment’s connection with self-concept and respect also plays into this, negative self-perception can be split off into one part and be separate from the positive aspects that can be left to function easily. (Ruth, 1997)
Breakdown of Attachment Through Complex Trauma
The attachment style formed in infancy and childhood will generally last throughout all of life. However, there are situations in which a secure attachment can be broken down later in life. Experiences of complex, usually interpersonal, trauma can make a secure attachment fall apart and leave someone in a position of insecure attachment. When looking at complex trauma we know that it can shake core beliefs of a person and create a feeling of nothing, no one being trustworthy, and hypervigilance and constant fear. These experiences counteract secure attachment.
Later child abuse during adolescence and intimate partner violence are common experiences that can break down secure attachment. Experiences like living in a war zone, being captive and more broadly long periods of trauma that are separated from the points of healthy attachment during adolescence can also break down attachment. The common factors are long term trauma, disconnection from previous caregivers, inability to escape the situation and perpetrators of violence usually being present.
Myths & Misconceptions About Attachment
Attachment theory has caught on in pop-psychology and in the “true crime” community. This has led to some poorly relayed information, misinformation and some over simplistic ideas being spread.
Myth: Attachment issues/lack of attachment is the cause or primary cause of someone becoming violent.
Fact: Attachment issues are not a predictor of “psychopathic” or violent behaviour. Especially within the true crime community, you see people throw out attachment theory as to why people become violent people, often serial killers. This is dangerous because it falls into being ableist and shaming people with mental health struggles. Attachment theory is a theory that for those with the most severe attachment issues were likely connected to trauma, not a theory of just violence behavior. Abuse survivors experience enough information we are destined to perpetrate violence against others, which we are not.
Myth: Lack of attachment means you become incapable of forming relationships or don’t need connection.
Fact: Attachment trauma can be healed. It doesn’t mean the person loses the need for social connection, or that they can never learn how. The person has a need and ability to love. Placing any people as incapable of love is inherently dehumanizing and demonizing. And to imply any person does not need social interaction and connection is contrary to what we all know, even people who enjoy much alone time need other people.
Myth: All attachment style are normal variations.
The majority of people have a secure attachment, framing it as simply “how your attachment style might be screwing with your love life” and not a neurodevelopmental process. This is almost the flip side of the problem pervasive in true crime and similar media, it trivialises a real problem.
Someone with a dismissive/avoidant attachment can’t just open and let people in easily, there is likely some degree of emotional neglect and should be looking to have wider healing. Anxiously attached people can’t stop being clingy without addressing the inability to conceptualize themselves outside of others perception. They also often avoid the flushed out concept of disorganized attachment completely, which shows that attachment trauma is apart of this theory meaning that while we all have relationship struggles its not at all a beginning variation.
Myth: All parents “screw us up a little”.
These articles often completely ignore trauma as a dimension or use a version that is not considering how developmental trauma is a wound on the core of who we are. The experience it takes to form a disorganized attachment is severe trauma, not all people suffer from developmental trauma. They use a frame without even using terms like disorganized ( or unresolved used in some literature about adults) term either from ignorance or because it requires experience and research to speak on developmental trauma, and it isn’t kitschy and fun to say. Ignoring trauma in people’s experiences always leaves out part of the story of psychology and gives false advice on healing.
This is also frustrating because many parents make little mistakes which are normal but offered some repair, these parents were perfectly fine parents. Putting them on the same level as truly abusive parents is wrong because it can make parents who did nothing feel bad, and parents who were abusive think it’s normal. The children of abusive parents might see their trauma symptoms presented as a normal variation and trivialized and new parents might worry about everything they do. It’s proven that most parents will not cause severe attachment issues, or be abusive.
Myth: Attachment styles apply to romantic relationships primarily or only.
The truth is that attachment has effects on self perception, regulation and all kinds of interpersonal relationships. This is problematic as it often erases the developmental impact of attachment and excludes its effects on wider psychosocial and physical health. It is such a common frame and it’s a huge problem because it also downplays platonic and familial bonds in a way that it is counterproductive to healing. Writing about attachment should not really be framed as an isolated relationship self-help fix-it concept without context.
Healing Attachment Trauma:
Attachment trauma can be healed over time. Healthy relationships, support networks, and treatment from therapists can all work to heal insecure attachments. Trauma-informed treatments that work on the integration of memories, embodiment in self, learning self-regulation and the ability to perform repair during relational rupture.
For children, there are also new ideas to prevent children from dealing with attachment issues and help parents not pass on their trauma to the child inadvertently. There is no magic form of therapy that heal attachment trauma there are modalities that can be very helpful in healing.
For Adult Survivors:
- Art and music therapy: Good for those dealing with problems verbalizing and expressing emotions.
- Dialectical Behavioural Therapy (DBT): Works on distress tolerance and emotional regulation
- Eye Movement Desensitization and Reprocessing Therapy (EMDR): This work to address more direct traumatic memories should someone have co-current PTSD.
- Family Systems Therapy (FST): Helps people deal with the parts of their mind dealing with trauma through different impulses. Offers a new conceptual framework for self-understanding and healing.
- Family Therapy: This works on repair work with partners, parents and other relevant people.
- Group Therapy: Can help form solidarity between those struggling with similar struggles. Also good to have some degree of support system formation if forming a tight knit one is hard for you, or it’s still hard to let them in.
- Re-parenting: helps fill in the holes parents left in guidance, self-soothing, confidence and interpersonal skills. Can be included within many kinds of therapy.
- Talk Therapy: Always a good place to start with, many therapists who may specialize in any subcategory will have an element of this. Whatever your struggling with starting here is a good idea. Also good to help work out what is going on.
- Trauma-informed bodywork: A process that can form an embodied life and self-regulation of the nervous system. This includes massage.
- Trauma-informed mindfulness: Helps work on self-regulation and dealing with hyperarousal.
- Trauma-informed yoga: Good for becoming in touch with the body and self-regulation.
For Parents and Children:
- Attachment and Biobehavioral Catch-up (ABC): A form of support for parents of children showing signs of attachment issues (usually based on RAD and DSED) and the child to become in line with the developmental age. Focused on teaching the parents to become supportive and to ensure they and the child learn to self regulate and co-regulate. Heavy focus of getting the parent to understand the child.
- Family Therapy: This works on repair work with partners/children and can help the whole family understand their issues.
- Parenting education: For dealing with a child with attachment issues
- Play Therapy: An excellent form of therapy for kids who are at levels of development who struggle with verbalization or are pre-verbal.
So Why Do We Care?
Understanding attachment can help people understand why they are dealing with what they are and to make sense of specific experiences with our caregivers and abusers (for many of us these are the same person).
Attachment theory can help people know what is making relationships so hard and begin to address what it is and form better relationships going forward. Knowing it’s a piece of other mental health struggles can also help be a piece in recovering from DID, BPD, or C-PTSD. It gives us words to explain our struggles and find others dealing with similar.
Knowing about development can also help work through how trauma works as well, and knowledge is power. When we understand our struggle we can better figure out what we need to do on our healing journeys.
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