Attachment theory 1,2,3 has proven to be a very fruitful framework for studying emotion regulation and mental health. In particular, research on adult attachment processes and individual differences in attachment orientations has provided strong evidence for the anxiety-buffering function of what Bowlby 2 called the attachment behavioral system and for the relevance of attachment-related individual differences to coping with stress, managing distress, and retaining psychological resilience 4.

In this paper, we offer a brief overview of the attachment perspective on psychopathology. Following a brief account of attachment theory's basic concepts, we review research findings showing that attachment insecurities — called attachment anxiety and avoidance in the theory — are associated with mental disorders, and that increases in attachment security are an important part of successfully treating these disorders.


  1. Top of page
  5. Mediating processes
  7. References

Bowlby 2 claimed that human beings are born with an innate psychobiological system (the attachment behavioral system) that motivates them to seek proximity to significant others (attachment figures) in times of need. Bowlby 1 also outlined major individual differences in the functioning of the attachment system. Interactions with attachment figures who are available in times of need, and who are sensitive and responsive to bids for proximity and support, promote a stable sense of attachment security and build positive mental representations of self and others. But when a person's attachment figures are not reliably available and supportive, proximity seeking fails to relieve distress, felt security is undermined, negative models of self and others are formed, and the likelihood of later emotional problems and maladjustment increases.

When testing this theory in studies of adults, most researchers have focused on the systematic pattern of relational expectations, emotions, and behavior that results from one's attachment history — what Hazan and Shaver 5 called attachment style. Research clearly indicates that attachment styles can be measured in terms of two independent dimensions, attachment-related anxiety and avoidance 6. A person's position on the anxiety dimension indicates the degree to which he or she worries that a partner will not be available and responsive in times of need. A person's position on the avoidance dimension indicates the extent to which he or she distrusts relationship partners’ good will and strives to maintain behavioral independence, self-reliance, and emotional distance. The two dimensions can be measured with reliable and valid self-report scales (e.g., 6), and they are associated in theoretically predictable ways with relationship quality and adjustment 4.

Mikulincer and Shaver 4 proposed that a person's location in the two-dimensional conceptual space defined by attachment anxiety and avoidance reflects both the person's sense of attachment security and the ways in which he or she deals with threats and distress. People who score low on these dimensions are generally secure and tend to employ constructive and effective affect-regulation strategies. Those who score high on either the attachment anxiety or the avoidance dimension (or both) suffer from insecurity and tend to rely on what Cassidy and Kobak 7 called secondary attachment strategies, either deactivating or hyperactivating their attachment system in an effort to cope with threats.

According to Mikulincer and Shaver 4, people scoring high on avoidant attachment tend to rely on deactivating strategies — trying not to seek proximity, denying attachment needs, and avoiding closeness and interdependence in relationships. These strategies develop in relationships with attachment figures who disapprove of and punish closeness and expressions of need or vulnerability 8. In contrast, people scoring high on attachment anxiety tend to rely on hyperactivating strategies — energetic attempts to achieve proximity, support, and love combined with lack of confidence that these resources will be provided and with resentment and anger when they are not provided 7. These reactions occur in relationships in which an attachment figure is sometimes responsive but unreliably so, placing the needy person on a partial reinforcement schedule that rewards persistence in proximity-seeking attempts, because they sometimes succeed.

Individual differences in attachment styles begin in interactions with parents during infancy and childhood (e.g., 9). However, Bowlby 3 claimed that meaningful relational interactions during adolescence and adulthood can move a person from one region to another of the two-dimensional conceptual space defined by attachment anxiety and avoidance. Moreover, a growing body of research shows that attachment style can change, subtly or dramatically, depending on current context, recent experiences, and recent relationships (e.g., 10,11).


  1. Top of page
  5. Mediating processes
  7. References

According to attachment theory, interactions with inconsistent, unreliable, or insensitive attachment figures interfere with the development of a secure, stable mental foundation; reduce resilience in coping with stressful life events; and predispose a person to break down psychologically in times of crisis 3. Attachment insecurity can therefore be viewed as a general vulnerability to mental disorders, with the particular symptomatology depending on genetic, developmental, and environmental factors.

Mikulincer and Shaver 4 reviewed hundreds of cross-sectional, longitudinal, and prospective studies of both clinical and non-clinical samples and found that attachment insecurity was common among people with a wide variety of mental disorders, ranging from mild distress to severe personality disorders and even schizophrenia. Consistently compatible results have also been reported in recent studies. For example, attachment insecurities (of both the anxious and avoidant varieties) are associated with depression (e.g., 12), clinically significant anxiety (e.g., 13), obsessive-compulsive disorder (e.g., 14), post-traumatic stress disorder (PTSD) (e.g., 15), suicidal tendencies (e.g., 16), and eating disorders (e.g., 17).

Attachment insecurity is also a key feature of many personality disorders (e.g., 18,19). However, the specific kind of attachment insecurity differs across disorders. Anxious attachment is associated with dependent, histrionic, and borderline disorders, whereas avoidant attachment is associated with schizoid and avoidant disorders. Crawford et al 18 found that attachment anxiety is associated with what Livesley 20 called the “emotional dysregulation” component of personality disorders, which includes identity confusion, anxiety, emotional lability, cognitive distortions, submissiveness, oppositionality, self-harm, narcissism, and suspiciousness. Crawford et al 19 also found that avoidant attachment is associated with what Livesley 20 called the “inhibitedness” component of personality problems, including restricted expression of emotions, problems with intimacy, and social avoidance.

Another related issue concerning the associations between attachment insecurities and psychopathology is the extent to which attachment insecurities are a sufficient cause of mental disorders. In our view, beyond disorders such as separation anxiety and pathological grief, in which attachment injuries are the main causes and themes, attachment insecurities per se are unlikely to be sufficient causes of mental disorders. Other factors (e.g., genetically determined temperament; intelligence; life history, including abuse) are likely to converge with or amplify the effects of attachment experiences on the way to psychopathology.

Consider, for example, the relation between attachment-related avoidance and psychological distress. Many studies of large community samples have found no association between avoidant attachment and self-report measures of global distress 4. However, studies that focus on highly stressful events, such as exposure to missile attacks, living in a dangerous neighborhood, or giving birth to a handicapped infant, have indicated that avoidance is related to greater distress and poorer long-term adjustment 4.

Life history factors are also important. For example, the association between attachment insecurity and depression is higher among adults with a childhood history of physical, psychological, or sexual abuse (e.g., 21). Stressful life events, poverty, physical health problems, and involvement in turbulent romantic relationships during adolescence also strengthen the link between attachment insecurity and psychopathology (e.g., 22).

The causal links between attachment and psychopathology are also complicated by research findings showing that psychological problems can increase attachment insecurity. Davila et al 23, for example, found that late adolescent women who became less securely attached over periods of 6 to 24 months were more likely than their peers to have a history of psychopathology. Cozzarelli et al 24 found that women who moved in the direction of insecure attachment over a 2-year period following abortion were more likely than other women who had an abortion to have a prior history of depression or abuse. Solomon et al 25 assessed attachment insecurities and PTSD symptoms among Israeli ex-prisoners of war (along with a matched control group of veterans) 18 and 30 years after their release from captivity. Attachment anxiety and avoidance increased over time among the ex-prisoners, and the increases were predicted by the severity of PTSD symptoms at the first wave of measurement.

Overall, attachment insecurities seem to contribute nonspecifically to many kinds of psychopathology. However, particular forms of attachment insecurity seem to predispose a person to particular configurations of mental disorders. The attachment-psychopathology link is moderated by a large array of biological, psychological, and socio-cultural factors, and mental disorders per se can erode a person's sense of attachment security.


  1. Top of page
  5. Mediating processes
  7. References

If attachment insecurities are risk factors for psychopathology, then the creation, maintenance, or restoration of a sense of attachment security should increase resilience and improve mental health. According to attachment theory, interactions with available and supportive attachment figures impart a sense of safety, trigger positive emotions (e.g., relief, satisfaction, gratitude, love), and provide psychological resources for dealing with problems and adversities. Secure individuals remain relatively unperturbed during times of stress, recover faster from episodes of distress, and experience longer periods of positive affectivity, which contributes to their overall emotional well-being and mental health.

In some of our studies, we have examined the effects of increased security on various indicators of mental health by experimentally activating mental representations of supportive attachment figures (e.g., 26,27). These research techniques, which we 11 refer to as “security priming”, include subliminal pictures suggesting attachment-figure availability, subliminal names of people designated by participants as security-enhancing attachment figures, guided imagery highlighting the availability and supportiveness of an attachment figure, and visualization of the faces of security-enhancing attachment figures.

Security priming improves participants’ moods even in threatening contexts and eliminates the detrimental effects of threats on positive moods (e.g., 26). Mikulincer et al 28 found that subliminal priming with security-related words mitigated cognitive symptoms of PTSD (heightened accessibility of trauma-related words in a Stroop-color naming task) in a non-clinical sample. Admoni 29 found that priming the names of each participant's security providers mitigated two cognitive symptoms of eating disorders (distorted body perception and heightened accessibility of food-related words in a Stroop task) in a sample of women hospitalized for eating disorders.

There is also preliminary evidence that a sense of security provided by a psychotherapist improves a client's mental health. In a study based on data from the multi-site National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program, Zuroff and Blatt 30 found that a client's positive appraisals of his or her therapist's sensitivity and supportiveness predicted relief from depression and maintenance of therapeutic benefits over an 18-month period. The results were not attributable to patient characteristics or severity of depression. In a one-year prospective study of the effectiveness of residential treatment of high-risk adolescents, Gur 31 found that staff members’ provision of a sense of attachment security in the adolescents resulted in lower rates of anger, depression, and behavioral problems. Although these preliminary findings are encouraging, there is still a great need for additional well-controlled research examining the long-term effects of security-enhancing therapeutic figures on clients’ mental health.

Mediating processes

  1. Top of page
  5. Mediating processes
  7. References

According to attachment theory 3, the linkage between attachment insecurities (whether in the form of anxiety, avoidance, or both) and psychopathology is mediated by several pathways. In this section, we will review the most important of these pathways.


According to attachment theory and research, lack of parental sensitivity and responsiveness contributes to disorders of the self, characterized by lack of self-cohesion, doubts about one's internal coherence and continuity over time, unstable self-esteem, and over-dependence on other people's approval (e.g., 32,33). Insecure people are likely to be overly self-critical, plagued by self-doubts, or prone to using defenses, such as destructive perfectionism, to counter feelings of worthlessness and hopelessness (e.g., 34). These dysfunctional beliefs about oneself increase insecure people's risk for developing mental disorders.

Attachment research has also shown that attachment insecurities are associated with pathological narcissism (e.g., 35). Whereas avoidant attachment is associated with overt narcissism or grandiosity, which includes both self-praise and denial of weaknesses 36, attachment anxiety is associated with covert narcissism, characterized by self-focused attention, hypersensitivity to other people's evaluations, and an exaggerated sense of entitlement 36.

Emotion regulation

According to attachment theory, interactions with available attachment figures and the resulting sense of attachment security provide actual and symbolic supports for learning constructive emotion-regulation strategies. For example, interactions with emotionally accessible and responsive others provide a context in which a child can learn that acknowledgment and display of emotions is an important step toward restoring emotional balance, and that it is useful and socially acceptable to express, explore, and try to understand one's feelings 37.

Unlike relatively secure people, avoidant individuals often prefer to cordon off emotions from their thoughts and actions. As a result, they tend to present a façade of security and composure, but leave suppressed distress unresolved in ways that impair their ability to deal with life's inevitable adversities. This impairment is particularly likely during prolonged, demanding stressful experiences that require active coping with a problem and mobilization of external sources of support (e.g., 38).

People who score high on attachment anxiety, in contrast, often find negative emotions to be congruent with their attachment-system hyperactivation. For them, “emotion regulation” can mean emotion amplification and exaggeration of worries, depressive reactions to actual or potential losses and failures, and PTSD intrusion symptoms following traumas. Attachment anxiety is also associated with socially destructive outbursts of anger and impulsive, demanding behavior toward relationship partners, sometimes including violence 4.

Problems in interpersonal relations

According to attachment theory, recurrent failure to obtain support from attachment figures and to sustain a sense of security, and the resulting reliance on secondary attachment strategies (hyperactivation and deactivation), interfere with the acquisition of social skills and create serious problems in interpersonal relations. Bartholomew and Horowitz 32, using as an assessment device the Inventory of Interpersonal Problems 39, found that attachment anxiety was associated with more interpersonal problems in general. Secure individuals did not show notable elevations in any particular sections of the problems circle, but avoidant people generally had problems with nurturance (being cold, introverted, or competitive), and anxious people had problems with emotionality (e.g., being overly expressive). These problems seem to underlie insecure individuals’ self-reported loneliness and social isolation (e.g., 40) and their relatively low relationship satisfaction, more frequent relationship breakups, and more frequent conflicts and violence 4.


  1. Top of page
  5. Mediating processes
  7. References

Attachment insecurities are associated with a wide variety of mental disorders, ranging from mild negative affectivity to severe, disorganizing, and paralyzing personality disorders. The evidence suggests that insecure attachment orientations (whether anxious or avoidant) are fairly general pathogenic states. Although many of the research findings supporting these ideas are correlational, several studies show a prospective connection between attachment insecurities and vulnerability to disorders. From a therapeutic standpoint, we have reviewed preliminary evidence that situationally heightening people's sense of attachment security reduces the likelihood and intensity of psychiatric symptoms (e.g., PTSD, eating disorders). This evidence underscores the soothing, healing, therapeutic effects of actual support offered by relationship partners, including therapists, and the comfort and safety offered by mental representations of supportive experiences and loving and caring attachment figures. The research evidence causes us to be optimistic about the utility of clinical interventions that increase clients’ sense of attachment security.

In the long run, research on attachment security and insecurity, and on the connections between insecurity and psychopathology, should contribute to a strongly social conception of the human mind and its vulnerability to pathologies. In a pioneering chapter on the social neuroscience of attachment processes, Coan 41 proposed what he calls social baseline theory. According to this theory, the human brain evolved in a highly social environment, and many of its basic functions rely on social co-regulation of emotions and physiological states. This means that, rather than conceptualizing human beings as separate entities whose interactions with each other need to be understood, it makes more sense to consider social relatedness and its mental correlates as the normal “baseline” condition. Using this as a starting point helps us to see why experiences of separation, isolation, rejection, abuse, and neglect are so psychologically painful, and why dysfunctional relationships are often the causes or amplifiers of mental disorders.


  1. Top of page
  5. Mediating processes
  7. References
  • 1
    Bowlby J. Attachment and loss, Vol. 2. Separation: anxiety and anger. New York: Basic Books, 1973.
  • 2
    Bowlby J. Attachment and loss, Vol. 1. Attachment (2nd ed.). New York: Basic Books, 1982.
  • 3
    Bowlby J. A secure base: clinical applications of attachment theory. London: Routledge, 1988.
  • 4
    Mikulincer M, Shaver PR. Attachment in adulthood: structure, dynamics, and change. New York: Guilford, 2007.
  • 5
    Hazan C, Shaver PR. Romantic love conceptualized as an attachment process. J Pers Soc Psychol 1987; 52: 51124.
  • 6
    Brennan KA, Clark CL, Shaver PR. Self-report measurement of adult romantic attachment: an integrative overview. In: Simpson JA, Rholes WS (eds). Attachment theory and close relationships. New York: Guilford, 1998: 4676.
  • 7
    Cassidy J, Kobak RR. Avoidance and its relationship with other defensive processes. In: Belsky J, Nezworski T (eds). Clinical implications of attachment. Hillsdale: Erlbaum, 1988: 30023.
  • 8
    Ainsworth MDS, Blehar MC, Waters E et al. Patterns of attachment: assessed in the Strange Situation and at home. Hillsdale: Erlbaum, 1978.
  • 9
    Waters E, Merrick S, Treboux D et al. Attachment security in infancy and early adulthood: a twenty-year longitudinal study. Child Dev 2000; 71: 6849.
  • 10
    Baldwin MW, Keelan JPR, Fehr B et al. Social-cognitive conceptualization of attachment working models: availability and accessibility effects. J Pers Soc Psychol 1996; 71: 94109.
  • 11
    Mikulincer M, Shaver PR. Boosting attachment security to promote mental health, prosocial values, and inter-group tolerance. Psychol Inq 2007; 18: 13956.
  • 12
    Catanzaro A, Wei M. Adult attachment, dependence, self-criticism, and depressive symptoms: a test of a mediational model. J Pers 2010; 78: 113562.
  • 13
    Bosmans G, Braet C, Van Vlierberghe L. Attachment and symptoms of psychopathology: early maladaptive schemas as a cognitive link? Clin Psychol Psychother 2010; 17: 37485.
  • 14
    Doron G, Moulding R, Kyrios M et al. Adult attachment insecurities are related to obsessive compulsive phenomena. J Soc Clin Psychol 2009; 28: 102249.
  • 15
    Ein-Dor T, Doron G, Solomon Z et al. Together in pain: attachment-related dyadic processes and posttraumatic stress disorder. J Couns Psychol 2010; 57: 31727.
  • 16
    Gormley B, McNiel DE. Adult attachment orientations, depressive symptoms, anger, and self-directed aggression by psychiatric patients. Cogn Ther Res 2010; 34: 27281.
  • 17
    Illing V, Tasca GA, Balfour L et al. Attachment insecurity predicts eating disorder symptoms and treatment outcomes in a clinical sample of women. J Nerv Ment Dis 2010; 198: 6539.
  • 18
    Crawford TN, Livesley WJ, Jang KL et al. Insecure attachment and personality disorder: a twin study of adults. Eur J Personality 2007; 21: 191208.
  • 19
    Meyer B, Pilkonis PA. An attachment model of personality disorders. In: Lenzenweger MF, Clarkin JF (eds). Major theories of personality disorder. New York: Guilford, 2005: 23181.
  • 20
    Livesley WJ. Classifying personality disorders: ideal types, prototypes, or dimensions? J Pers Disord 1991; 5: 529.
  • 21
    Whiffen VE, Judd ME, Aube JA. Intimate relationships moderate the association between childhood sexual abuse and depression. J Interpers Violence 1999; 14: 94054.
  • 22
    Davila J, Steinberg SJ, Kachadourian L et al. Romantic involvement and depressive symptoms in early and late adolescence: the role of a preoccupied relational style. Pers Relationship 2004; 11: 16178.
  • 23
    Davila J, Burge D, Hammen C. Why does attachment style change? J Pers Soc Psychol 1997; 73: 82638.
  • 24
    Cozzarelli C, Karafa JA, Collins NL et al. Stability and change in adult attachment styles: associations with personal vulnerabilities, life events, and global construals of self and others. J Soc Clin Psychol 2003; 22: 31546.
  • 25
    Solomon Z, Dekel R, Mikulincer M. Complex trauma of war captivity: a prospective study of attachment and post-traumatic stress disorder. Psychol Med 2008; 38: 142734.
  • 26
    Mikulincer M, Hirschberger G, Nachmias O et al. The affective component of the secure base schema: affective priming with representations of attachment security. J Pers Soc Psychol 2001; 81: 30521.
  • 27
    Mikulincer M, Shaver PR. Attachment theory and intergroup bias: evidence that priming the secure base schema attenuates negative reactions to out-groups. J Pers Soc Psychol 2001; 81: 97115.
  • 28
    Mikulincer M, Shaver PR, Horesh N. Attachment bases of emotion regulation and posttraumatic adjustment. In: Snyder DK, Simpson JA, Hughes JN (eds). Emotion regulation in families: pathways to dysfunction and health. Washington: American Psychological Association, 2006: 7799.
  • 29
    Admoni S. Attachment security and eating disorders. Doctoral dissertation, Bar-Ilan University, Ramat Gan, Israel, 2006.
  • 30
    Zuroff DC, Blatt SJ. The therapeutic relationship in the brief treatment of depression: contributions to clinical improvement and enhanced adaptive capacities. J Consult Clin Psychol 2006; 74: 199206.
  • 31
    Gur O. Changes in adjustment and attachment-related representations among high-risk adolescents during residential treatment: the transformational impact of the functioning of caregiving figures as a secure base. Doctoral dissertation, Bar-Ilan University, Ramat Gan, Israel, 2006.
  • 32
    Bartholomew K, Horowitz LM. Attachment styles among young adults: a test of a four-category model. J Pers Soc Psychol 1991; 61: 22644.
  • 33
    Park LE, Crocker J, Mickelson KD. Attachment styles and contingencies of self-worth. Pers Soc Psychol B 2004; 30: 124354.
  • 34
    Wei M, Heppner PP, Russell DW et al. Maladaptive perfectionism and ineffective coping as mediators between attachment and future depression: a prospective analysis. J Couns Psychol 2006; 53: 6779.
  • 35
    Dickinson KA, Pincus AL. Interpersonal analysis of grandiose and vulnerable narcissism. J Pers Disord 2003; 17: 188207.
  • 36
    Wink P. Two faces of narcissism. J Pers Soc Psychol 1991; 61: 5907.
  • 37
    Cassidy J. Emotion regulation: influences of attachment relationships. Monogr Soc Res Child Dev 1994; 59: 22883.
  • 38
    Berant E, Mikulincer M, Shaver PR. Mothers' attachment style, their mental health, and their children's emotional vulnerabilities: a seven-year study of children with congenital heart disease. J Pers 2008; 76: 3166.
  • 39
    Horowitz LM, Rosenberg SE, Baer BA et al. Inventory of Interpersonal Problems: psychometric properties and clinical applications. J Consult Clin Psychol 1988; 56: 88592.
  • 40
    Larose S, Bernier A. Social support processes: mediators of attachment state of mind and adjustment in late adolescence. Attach Hum Dev 2001; 3: 96120.
  • 41
    Coan JA. Toward a neuroscience of attachment. In: Cassidy J, Shaver PR (eds). Handbook of attachment: theory, research, and clinical applications (2nd ed.). New York: Guilford, 2008: 24168.