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 Lucy Cumyn* Published: 19 May 2016 Department of Psychiatry, Douglas Mental Health University Institute, Canada Copyright © 2016 Cumyn et al. 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 significant 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 protectioncommunicates from emotional threat, which understanding in turn, gives[31]. Thesethem 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 understoodconsider a unifiedas an ‘attachmentdefinition of disorder’? RAD and school performance [34]. Secure attachments therefore form Inwhere other it maywords, (or themay literature not) fit in seems with attachment divided and theory what so is thatthe 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 candevelopment be classified and as traumaticconsequent 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 colleaguesstyles in infantsalso made between significant 9-18 perspectives. monthscontributions old and to theirattachment caregivers theory. using They the wereStrange the Situation