Clarifying “Disorder” in Attachment: an Overview

Central Annals of Psychiatry and Mental Health

Review Article *Corresponding author Lucy Cumyn, Department of Psychiatry, Douglas Mental Health University Institute, 1105-401 Carling Avenue, Ottawa, Ontario, Canada, Tel: 514- Clarifying “Disorder” in 386-8971; Fax: 613-729-8484; Email:

Attachment: An Overview Submitted: 21 March 2016 Accepted: 10 May 2016

Abstract ISSN: 2374-0124 In the past decade, attachment theory has undergone an intense expansion OPEN ACCESS of both its original scientiﬁc foundations as well as its applications to clinical work. Bowlby’s original description occurred during a period of behaviorism and then an Keywords emphasis on secure base behaviors gave way to dominance of cognitive perspectives. • RAD The article then describes another model that draws from both these theories and • Attachment disorders integrates a psychopathological component of attachment using a developmental and • Complex trauma information processing perspective. The discussion leads to the role of trauma and the inherent omission from the Diagnostic and Statistical Manual of Mental Disorders (DSM-V, 2013) criteria for reactive attachment disorder (RAD) even though empirical work has documented the signifcant and negative impact this has on the development of RAD. The shift moves from the pathology within the individual child to the caregiver’s inability to mentalize or provide a safe environment; the latter constitutes as a type of ‘trauma’ and has been shown to have neurological effects responsible for secure attachment in the child.

ABBREVIATIONS [11]. Other debates have focused on the relations between

DSM: Diagnostic and Statistical Manual of Mental Disorders; disorganization. Research has been limited largely due to a lack RAD: Reactive Attachment Disorder ofattachment universally classifications accepted diagnostic and clinical protocol disorders [3] thereby of attachment the nature INTRODUCTION of maladaptive attachment and its link to psychopathology remains uncertain [12]. Given that these features of attachment According to the Diagnostic and Statistical Manual of Mental disorders seem somewhat unresolved, it is not surprising that Disorders-Fifth Edition (DSM-V), the core feature of reactive the areas of assessment and intervention hold the greatest attachment disorder (RAD) is severely inappropriate social amount of uncertainty and controversy [13]. Consequently, the absence of an appropriate diagnosis may therefore act as a [1]. It is a more extreme psychiatric diagnosis for a subgroup barrier to effective treatment [11] especially since children with relating that begins in children before they are five years old RAD often have comorbid conditions [3]. An accurate diagnosis is attachments [2]. Although the concept of attachment disorders of children with the most significant and detrimental insecure has been described in the clinical literature for over 50 years appropriate, safe, and evidence based interventions [14,5] that [3], RAD is considered by some, a relatively new diagnosis [4,5]. arerequisite also feasible to ensure and that realistic children in with terms multiple of the difficultiesglobal picture; receive in As such, it has been one of the least researched [5,6] and most other words, effective interventions target families and children’s poorly understood disorders in the Diagnostic and Statistical mental health issues [4]. Manual of Mental Disorders – Fourth Edition (DSM-IV), [7] with little systematically gathered epidemiological information [8]. In brief, the literature on attachment disorders is messy and Some mental health professionals assert that the etiology is somewhat unclear. O’Connor and Zeanah [13] describe the area as largely unknown [4] but the consensus seems to point towards somewhat of a paradox because evidence shows that attachment some level of disruption between a caregiver and a child [9]. disorders warrant clinical attention and there are known factors that contribute to the disturbances, associated conditions, and of the term ‘attachment disorder’ but that a better understanding the longitudinal course. However, there is still no consensus or Newman and Mares [3] wrote that there is no accepted definition protocol for assessing the disorder and related behaviors [13]. problems as there is symptom overlap and when it comes to Zilberstein [5] underlined that, “RAD has been written about by diagnosis,might require there a tighter can be definition a number of ofRAD false [8]. positivesThis is not and without false researchers and clinicians grounded in Bowlby’s [15] attachment negatives (p.77). Some argue that the DSM-IV [7] criteria may not theory, by those who call themselves holding therapists, and by be reliable [10] and that the DSM-V [1] lacks specific taxonomies those who study severe early deprivation in adopted children. The Cite this article: Cumyn L (2016) Clarifying “Disorder” in Attachment: An Overview. Ann Psychiatry Ment Health 4(4): 1069. Cumyn et al. (2016) Email: Central lack of clarity is exacerbated by the fact that each of these groups communications (voice tone, touch, gestures, and vocalizations presumes different etiologies, presentations, and treatments of [30] with a sensitive caregiver who is attuned to the infant’s the disorders” (p.55) even though there seems to be some overlap interactions form affective relationships and offer infants and of this paper is to not add to the confusion but to tease apart and childrenstate and protection communicates from emotional threat, which understanding in turn, gives[31]. These them simplifyin terms someof what of isthese meant controversies by attachment. and Therefore, shed light the on purposewhat is comfort and nurturance. Secure attachment also teaches social interaction, emotional development such as regulating feelings [15,32], physiological development, and overall psychological now known in terms of defining attachment, understanding the well-being [33] such as stress management, regulating etiology, the implications for treatment and more specifically, behaviors, integrating experiences, learning social skills, and itRAD. can Is be it commonlypossible to understood consider a unified as an ‘attachment definition of disorder’? RAD and school performance [34]. Secure attachments therefore form Inwhere other it may words, (or themay literature not) fit in seems with attachment divided and theory what so is that the the foundation for a healthy development that allows children to usefulness of two separate entities that are seemingly related? explore and return to a secure base when feeling overwhelmed or threatened [15]. In contrast, insecure attachment occurs diagnosis and treatment it seems intuitive to modify the criteria with disruptions of affective and secure bonds and negative soThe that DSM-V it can [1] be is used a different to help ball focus of onpolitical the child wax and but subsequentin terms of experiences such as loss, separation, misattunement, violence, family needs. Otherwise, the literature at this point will continue such as anxiety, depression, anger or emotional detachment; the literature on various perspectives of attachment theory (a abuse or neglect. Children can develop psychological difficulties detailedto remain discussion divided. The is beyond paper willthe scopebegin ofby this summarizing paper), on some related of withwhich attachment in turn can insecurity lead to relationalcan have a and profound social effect difficulties on a child’s [35]. will in turn, lead to a discussion about treatment implications. neurophysiologicalThese experiences can development be classified and as traumatic consequent and restricted coupled controversies throughout the field on attachment disorders which capacities such as somatic and emotional dysregulation, and Overview of attachment identify formation [35-36]. O’Connor and Zeanah [13] summarized various terms Bowlby [29] also described the concept of internal or throughout the history of the attachment literature used to refer inner working models (IWM), where children unconsciously to a child’s disturbed manner of social behaviors and the ways in which they approached and interacted with strangers. For form mental representations of relationships based on their interactions with, and adaptation to, their primary caregiving [17], indiscriminately friendly [18,19], affectionless psychopathy instance superficially affectionate [16], indiscriminate exhibition them organize affect and social experiences which, in turn, shape [20] or an excessive need for adult attention [21] described environment. These cognitive/affective representations help children who experienced institutional care and exhibited current and future interpersonal relationships and behaviors behaviors consistent with the DSM-IV’s [7] disinherited form [35,33]. Bowlby’s view of early childhood attachments was of attachment disorder [13]. Furthermore, it was shown that instinctive in nature, suggesting a biological motive [9]. these symptoms remained stable throughout their childhood and adolescence. Since then, the literature seems to have been divided into different camps depending on theoretical or clinical empiricallyMary Ainsworth study attachment and her colleagues styles in infants also made between significant 9-18 perspectives. monthscontributions old and to their attachment caregivers theory. using They the were Strange the Situation first to developmental psychology, the concept of attachment seems to the amount of exploration by the child throughout the situation, Procedure (SPP) [22-24]. The lab setting allowed them to observe be mostTo the commonly layperson associated or perhaps with someone John Bowlby’s new to [15]the field theory of their reactions when the caregiver left, stranger anxiety (alone of attachment and later Mary Ainsworth’s work with children with the stranger and without the caregiver), and the reunion and the Strange Situation Procedure (SSP) [22-24]. Although behavior (with the caregiver returned). Initially, three basic attachment theory per se is currently not used as a basis for patterns were delineated that described the quality and affective diagnosis in the DSM (as it strives to be theoretical [25], it does characteristics of a child’s attachments: organized (a strategy constitute the key theoretical foundation for research and clinical work on attachment problems and no paper is complete without used to gain proximity of an attachment figure) or disorganized mention of these tenets as they remain critical in understanding of fear). Organized attachments refer to patterns that are (children who have an attachment figure who is also a source the components of attachment disorders [5]. classified according to whether the child feels secure (safe) or was built on concepts from etiology and developmental ininsecure/anxious reality they are regarding safe and the vice availability versa; hence, or responsiveness feeling states. psychology.John Bowlby’s He presented first formal three statement papers of attachment to the British theory of the attachment figure. A child may feel insecure although his mother” [26-27] and “Grief and mourning in infancy and early threeInsecure patterns, organized a fourth attachments category are of eitherattachment avoidant was or developed: resistant/ childhood”Psychoanalytic [28]. Society Bowlby in [29]London: showed “The the nature critical of the importance child’s tie toof ambivalent [22,24]. When some infants did not fit into the stable or secure attachment in humans and primates whereby attachment is based on the responsiveness and availability of the disorganized/disorientedWhen dealing with the insecure stress attachment of separation, [37-38]. disorganized caregiver. Early attachments form through verbal and nonverbal

infants lacked a coherent, organized strategy. Their behaviors Ann Psychiatry Ment Health 4(4): 1069 (2016) 2/7 Cumyn et al. (2016) Email: Central indicated not only a lack of organization but also orientation psychopathology is that 1) it differentiates many atypical strateThegies contribution as opposed to of considering this model most psychiatric in understanding patients (dis-orientation). This was further classified along a continuum as disorganized and 2) it provides a theoretical model of how canfrom be no strong, signs offrequent disorientation or extreme or disorganization [37]. Main and to,Hesse definite [38] strategies develop in terms of maturing abilities to process alsoqualification showed that for disorganized attachment attachment behaviors – infant in behaviors infancy protective function of atypical strategies [43]. Five ideas underlie named two more groups to the Disorganized group: controlling theinformation DMM: patterns (information of attachment processing) as a) and self-protective 3) it specifies strategies, the self- punitivedeveloped (child into tries controlling to humiliate behaviors or reject in later the childhood. caregiver) They and b) that are learned in interaction with protective or attachment controlling-caregiving (child shows caregiving suggestive of role reversal) [38]. Of all the types of attachments, disorganized e.g. acting out or consequent to a strategy or anxious behaviors, children tend to be at the highest risk for later behavioral and d)figures, strategies c) symptoms that will that change are functional when individualsaspects of dyadic perceive strategy, that

both believe and feel it is safe to behave in alternative ways. emotional difficulties [5]. they do not fit the context, have alternative responses, and e) the Dynamic Maturational model of attachment (DMM), was An alternative classification of attachment behaviors, organized around experienced outcomes that are expected to re- developed by Crittenden [39] and draws from Bowlby [29,15] There are two patterns of attachment: Type A (strategies are C (strategies are motivated by somatic feelings tied to intensity an attachment based approach across the lifespan and situates ofoccur); stimulation awareness and of processed negative feelings through are limbic minimized structures and, in Type the problemsand Ainsworth’s within work a context [22,24]. of family-attachmentThis model (Figure relationships.1) integrates brain. Feelings are used as a guide for behavior and tend to be

The theory is about a) protecting the self and one’s progeny of open, direct, and reciprocal communication of expectations developmental theory, the model includes “interactive effects of negative. Type B integrates cognitions and affect and consists from danger, and b) finding a reproductive partner [39]. As a balance and is least vulnerable to psychopathology (synonymous experience to produce individual differences in strategies for and feelings. This strategy is described as one of psychological genetic inheritance, maturational processes, and person-specific with Bowlby’s notion of secure attachment). Balance enables individuals to be safe and feel comfortable in diverse situations of attachment) describe interpersonal behaviors but also a keeping oneself safe”, p. 105 [40]. These strategies (patterns [43]. model also places more emphasis on the effect of maturation in creatingfunctional the system possibility for diagnosing for change psychopathology in developmental [41]. pathways This and less on the cumulative effects of early conditions that can The DMM of attachment model includes compulsive Type A andstrategies organizations and obsessive of information Type C strategies that infants [39,43]. cannot The handle; higher theory of psychopathology and draws on Bowlby’s [15] notions numeral strategies reflect transformations of information oflimit exposure human to potential danger [42].that effects The DMM psychology also purports and behavioral to be a functioning [39]. feigneddistorted helpless) affect andand cognitionfalse affect occur and cognition mid-model are (Typeat the bottom A 3-4: compulsively caregiving/compliant, Type C 3-4: aggressive/ maturation and psychopathological problems become possible of the model (Type AC: psychopathy). The patterns increase with

when someone is in their early twenties [43].The Dynamic- combinationsMaturational modelof A and of C attachmentstrategies of [39].which The psychopathy B strategies are arethe balanced with regard to cognition and affect. There are various of this model is that the most serious disorders of adolescence andmost adulthood,distorted, dangerous, personality and disorders, endangered psychoses [43]. The can advantage be seen as cumulative effects of a series of developmental insults and consequent transformations of information [43]. In sum, the DMM of attachment theory focuses on protection and reproduction as central organizing functions and on the array of ways that these may be manifested. Representation is seen as an intra-personal process derived from the interpersonal context including

and do not describe a person’s characteristic but rather their actions.attachment Both figures. presentation Behavioral and strategic strategies action are are interpersonal due to the interactive outcome of maturational processes, individual

the DMM is an information processing model with implications forgenetic treatment. differences, Crittenden and unique [43] contends environmental that it contexts. contributes Thus, to the understanding of psychopathology as it includes a model Figure 1 of functional formations and development based hypotheses The Dynamic-Maturational Model of Attachment [43]. Ann Psychiatry Ment Health 4(4): 1069 (2016) 3/7 Cumyn et al. (2016) Email: Central regarding the relation of childhood experiences related to later psychopathology [43]. Empirical support from some infant than as a discrete form of attachment disorder [12]. studies suggests that the DMM has validity for maltreatment correctly viewed as profiles of attachment disorders behaviors relationships, placing the criteria for diagnosis on a child’s empirical support for this model with adolescents and adults problematicThe DSM socialalso focuses behavior on andindiscriminate not on attachment and inhibited per se social [46]. butand furtherbehavioral exploration or psychiatric of the disorders relation [44-45].between There the DSM is less or the conception of attachment fostered by attachment theory: “AttachmentThe DSM focuses involves on individual the mutual pathology and trusting but itrelationship contrasts withof a toInternational bridge the Classificationgap between oftheory Diseases and (ICD) clinical diagnoses psychopathology and DMM child with a primary caretaker”, p.56 [5] but this is not outlined in andclassifications does it have is warranted the potential [43]. to Does explain the DMM how modelRAD falls commence on the continuum of attachment disorders? According to Zeanah, attachment theory is a theory of skillsthe DSM. and The availability dynamic ofand the reciprocal caregiver. nature For instance,of the relationship pathogenic is development and not of pathology because it does not clearly parenting,important as such a dysfunctional as abuse and one trauma, could reflect is associated a lack of with relational infant demarcate between normal variations of attachment and a disorganization [53] and not solely the child’s internalized disorder [46]. Sroufe [47] states that psychopathology is often important implications to consider: one for treatment and the (including temperament, medical conditions, environmental otherschema for ofa better attachment. understanding This latter of the point etiology has of two the disorder. main and factorsmulti-determined and relationships and is the as well result as of trauma) a confluence [5]. Attachment, of factors A psycho-dynamically informed approach addresses the therefore, could be just one component in the global picture. When latter point and looks at the role of trauma and how it affects the psychopathology is present, it is better predicted by multiple risk development of attachment and the disruption of brain structures, factors combined than just by disorganized attachment alone neuro-chemicals, and connectivity. Neurobiological effects of [48]. Although, Crittenden’s DMM [43] seems to have started to childhood neglect equal and even surpass the impact of abuse and related trauma [9]. Early emotional and attachment experiences development of relationships or of the ways in which distortions are affected by pathogenic care giving, the absence of caregivers infill relationships in this gap, there play ais role still ina lackthe child’s of understanding psychopathology between [12]. the or the disruption of an early care giving environment; these types of neglect affect the ability of the hypothalamic-pituitary-adrenal of developmentTo delineate iswhich both problems continuous in aand given evolving child derive [47]. Zilberstein from poor right hemisphere and its connected structures are dominant [5]attachments proposes orthree from axes other to examinefactors is attachment difficult because that do the not process seem duringaxis to regulate early attachment the body and experiences brain’s response and interactions, to stress [9]. such The as facial mirroring and mutual gaze attunement, between the infant categorical or continuously distributed: attachment security, and caregiver [36,54]. Without appropriate dyadic attachment attachmentto be inherently intensity, included and additional in the DMM. clinical These signs axes or are patterns. either experiences during infancy, children grow into adulthood lacking Although attachment theory makes clear that early relationships self-soothing abilities, self-organization, and the ability to engage are important to development it does not extrapolate directly to in healthy relationships [55]. understanding attachment disorders. Attachments vary across RAD in the DSM-V [1] is understood to be caused by “a secure, insecure, and disorganized presentations but in terms of RAD, the variations in attachment or severity of attachment one of the following conditions: 1. Social neglect or deprivation inpattern the form of extremes of persistent of insufficient lack of having care” basic as evidenced emotional by needs at least for comfort, stimulation, and affection met by care giving adults. 2. difficulties is not recognized as part of a RAD diagnosis. In sum, explained by components of the DMM model [43]. Repeated changes of primary caregivers that limit opportunities the inventories of RAD symptoms in the DSM are not specifically Similarly, RAD symptoms often extend beyond what is found to form stable attachments, e.g. frequent changes in foster care. in the DSM [4] and none of the types of attachments described in 3. Rearing in unusual settings that severely limit opportunities attachment theory directly correspond with attachment disorders to form selective attachments, e.g. institutions with high child-to in the DSM-V [1,5]. Some case studies of children with RAD caregiver ratios” [1]. As seen earlier in this paper, Bowlby [28] suggested that the behaviors [49-51] and insecure patterns [52]. Given that biological motive for attachment was instinctive. Early, secure have cited the prevalence of disorganized (Type D) attachment attachment experiences form the foundation of a child’s healthy in long term or foster care, very few present with discrete (or object-relationship; this provides the dyadic and reciprocal relationship difficulties are extremely common among children experiences that shape infant inter-subjectivity [9] and the example, an epidemiological study of 347 children in long term infant’s ability to become resilient: the capacity to withstand and pure) forms of social or interpersonal relationship difficulties. For could be construed as ‘discrete’ mental disorders or comorbidity, foster care, while 35% of children had clinical difficulties that another 20% displayed complex attachment and trauma related incope a secure with adversity. environment. The infant Research also onlearns infants to self-regulate at one month (delay old, symptoms that are not adequately conceptualized within the DSM showedgratification seeking and out self-object interactions relations) with others, provided they by also the listened mother

[12]. As such, some argue that many children in care present with developing brain and structures, neurotransmitters, neural or the International Classification of Diseases (ICD) classifications pathways,and watched affective those whoand cognitivedirected expressions systems help to understandthem [56]. Thethe a complex array of attachment related difficulties that are more Ann Psychiatry Ment Health 4(4): 1069 (2016) 4/7 Cumyn et al. (2016) Email: Central

by’s core ideas have been expanded into a more complex and limbic system, septal nuclei, the brain stem, and the structures and clinically relevant model…at this point in time, any theory of connectionsdevelopment in of the relationships coordination [9]. of Themotor amygdala, and expressive hypothalamus, activity development and its corresponding theory of therapy must are implicated in the meaning making of relationships with early emotional transactions with the primary object impact the environment, and behavior [9] and has implications for theinclude development these psychobiological of psychic structure,ﬁndings regarding that is, howprecisely affective how secureothers [57,58].attachment This that illustrates protects the against link between the psychopathological biology, genetics, attachment communications facilitate the maturation of brain care giving characteristic of RAD [31]. of an integrative interdisciplinary theory now encompasses allsystems the essentialinvolved in elements affect and that self-regulation. allow us to The comprehend rich intricacy and as a trauma as it can negatively impact the capacity to develop treat disorders of self and affect regulation more effectively” andPsychopathological maintain relationships care [35]. giving Given can that be the generally DSM-V outlines defined criteria that describe trauma and research shows the association regulation theory is an amalgam of Bowl by’s attachment theory, between trauma inducing experiences and psychological updated[32]. Therefore, internal theseobject authorsrelations concluded theories, self- that psychology, the concept and of contemporary relational theory; a developmental approach and its impact on neurological development, early trauma and its distress, including post-traumatic stress disorder (PTSD) [59] informed by both neuroscience and infant research. Attachment outcomes are thus the product of the interactions of nature shame [60] one is left wondering why the DSM-V [1] omits the and nurture, the strengths and weaknesses of the individual’s rolesecondary of trauma, difficulties or developmental in adulthood, trauma, e.g. substance from the use, taxonomy anxiety, genetically encoded biological predispositions (temperament) of RAD [11]. Rahim discusses the absence of developmental and the early dyadic relationships with caregivers embedded trauma disorder from the DSM-V as it raises implications within a particular social environment and culture. about how trauma and attachment can be conceptualized [11]. Although RAD is included in the updated DSM, it only describes ACKNOWLEDGEMENTS children who, due to emotional neglect or deprivation, do not seek comfort when distressed and who have a lack of positive Josée Ouellet, PhD., for your time, patience, and resourcefulness. Thanks and appreciation to my clinical supervisor, Marie- domestic violence, the physiological manifestations of emotional REFERENCES affect. The diagnostic criteria do not include the effects of 1. American Psychiatric Association. Diagnostic and Statistical Manual disturbance or functional impairment. The taxonomy “has not of Mental Disorders. 5th ed. 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Cite this article Cumyn L (2016) Clarifying “Disorder” in Attachment: An Overview. Ann Psychiatry Ment Health 4(4): 1069.

Ann Psychiatry Ment Health 4(4): 1069 (2016) 7/7