Preoccupied adult attachment style as a vulnerability factor in the prediction of PTSD
among security workers
Bogaerts, S.; Daalder, A.L.
Published in:Crimen et Delictum: International Journal of Criminological and Investigative Sciences
Publication date: 2011
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Bogaerts, S., & Daalder, A. L. (2011). Preoccupied adult attachment style as a vulnerability factor in the prediction of PTSD among security workers. Crimen et Delictum: International Journal of Criminological and Investigative Sciences, 2(1), 44-52.
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Preoccupied adult attachment style
as a vulnerability factor in the
prediction of PTSD among security
workers
Stefan Bogaerts1, Annelies Daalder2
Abstract
This study examines post traumatic stress disorder based on data collected in a sample of Belgian security workers (n=81). All individuals experienced a traumatic event in the previous 12 months. The sample was divided into a securely attached and an insecurely attached group. Two research questions were examined. Firstly, differ secure and insecure attached security workers on the examined PTSD scores (re-experiencing, avoidant and hyper arousal)? Secondly, which attachment style can be seen as a vulnerability factor in the prediction of PTSD? The PTSD symptom scales re-experiencing, avoidance and hyper arousal differentiated significantly between the secure and the insecure group. The preoccupied attachment style contributed independently to the prediction of PTSD. Interest has been expressed in medical approaches; therefore,
1 Full Professor of Forensic Psychology and Victimology at
Tilburg University, INTERVICT, Law School. Forensic Psychology, School of Social and Behavioral Sciences. Catholic University Louvain. Leuven Institute of Criminology (LINC), Faculty of Law. Head Research and Innovation Forensic Psychiatric Center De Kijvelanden/Dok Visiting Professor at the Advanced High School of Criminological Sciences – CRINVE. Member of LIBRA’s Advisory Board Association nonprofit – Network for the study and the development of dynamics of mediation. Advisory Board Crimen et Delictum – International Journal of Criminological and Investigative Sciences. Member of FDE’s Institute Press Advisory Board. S.bogaerts@uvt.nl
2 Head Commissioning Research Division WODC. Ministry of
Security and Justice, NL
we underlined separately the importance of medical research in relationship to PTSD.
Keywords: traumatic event, attachment style, PTSD, security workers
1. Introduction
The relationship between a traumatic event and the development of posttraumatic stress disorder (PTSD) has been established in a number of studies (Tagay et al., 2004; Momartin et al., 2004; Thatcher, Krikorian, 2005; Scarpa et al., 2006). PTSD is one of the most frequent and debilitating psychological disorders documented in the aftermath of, for instance, extreme life events, serious critical incidents and different forms of disasters (Gabriel, Ferrando, Sainz Cortón et al., 2007; Bogaerts, Kunst, Winkel, 2009). There is a tremendous amount of research in the area of
psychopathological consequences of
experiencing a traumatic life event. Researchers pointed out that psychological reactions such as stress reactions, panic attacks, anxiety, depression and PTSD often emerge after a traumatic event (Gabriel et al., 2007).
foreshortened future, feelings of detachment and a restricted range of affect. The third symptom cluster, increased arousal, is indicated by difficulty staying or falling asleep, anger and irritability, difficulty concentrating, and an exaggerated startle response (DSM-IV-TR, APA, 2000; Clair, 2006).
When a person becomes a victim or witness of a serious event, it is not surprising that this critical incident will affect the emotional and psychological well-being of the person. How someone reacts is individual and depends on many factors. It is not unusual when a person reacts the day after the life event with for example, crying, irritability, anger, sadness, fear, avoiding the crime scene and insomnia. These are normal ‘day after reactions’. When these symptoms persist after two weeks, a diagnosis of Acute Stress Disorder (ASD) may be appropriate. When the duration of the symptoms persists for more than one month, a diagnosis of PTSD may be warranted (DSM IV-TR, APA, 2000). Several studies suggest that the more traumatic events to which people are exposed, the more intense PTSD symptoms they are likely to experience. However, not everyone who has experienced numerous traumatic events develops more intense PTSD symptoms, indicating that other variables may influence this relationship as well (Clair, 2006).
Which people are more sensitive or vulnerable to develop PTSD after a traumatic event is an important question because of the debilitating effects of the disorder and also for treatment indication. Not every one who becomes a victim of a traumatic life event will suffer from PTSD afterwards. Several factors such as individual characteristics (e.g.,
personality, heritability, genetic factors, attachment quality, social skills and relational support), environmental factors (social networks, contacts with friends, family, neighbourhood, work), the number of traumatic life events experienced in one’s lifetime and the seriousness of the incident, determine whether or not an individual eventually develops PTSD after experiencing a traumatic event (Williams, 2006; Pomp, Spreen, Bogaerts et al., 2010). In this paper we focus on a group of Belgian security workers who experience risks and danger frequently because of the nature of their job. During their job, security workers are often exposed to danger and violence, such as intimidation, threat, aggression and shootings and are for that reason at risk for developing stress and PTSD (Schaufeli. Peeters, 2000; Declercq, Willemsen, 2006). We examine PTSD in a group of security workers who experienced a traumatic job related event in the previous twelve months. We examine whether or not the quality of adult romantic attachment style influences the development of PTSD.
nature and are formed particularly during the first years of life. Working models consist of cognitive components, positive and negative affective representations.
These representations are relating to inner experiences of the person, positive and negative experiences with significant attachment figures and with people who have crossed our path in the past (Main, Kaplan, Cassidy, 1985; Bretherton, 1995). Working models have shown to be rather stable across the life span (Main et al., 1985; Sroufe, Egeland, Kreutzer, 1990). As such, attachment styles developed in childhood may be predictive for the adult attachment style, obviously with the nuance that attachment styles may change even in adulthood (Main et al., 1985). Hazan and Shaver (1987) and Bartholomew (1990) developed and examined various models of adult attachment styles. Hazan and Shaver (1987) developed three categories of attachment (secure, avoidant and ambivalent) based on Ainsworth’s childhood attachment styles. Main et al. (1985) described four categories of attachment styles (secure-autonomous, dismissing, preoccupied and unresolved disorganized). Bartholomew (1990) argued that dismissing-avoidant individuals denounce feelings of subjective distress and dismiss the significance of attachment needs. Individuals who are classified as avoidant by using the Hazan-Shaver classification indicate relatively high levels of distress and apprehension about getting close to others. Regarding Muller et al. (2000), Bartholomew contends that two unique types of avoidance are apparent, one pattern motivated by a defensive maintenance of self-sufficiency, and the other motivated by a conscious fear of anticipated rejection (Muller et al., 2000, p. 323; Bartholomew, Shaver, 1998).
In this paper, we will not elaborate on differences between classifications of attachment styles because the focus in this paper is primarily on the question whether an insecure adult attachment style can be predictive for the development of PTSD. This means that PTSD can be defined as an affect regulation disorder resulting from the inability to cope adequate with a stressful or critical event (Muller et al., 2000). Certain attachment styles can create a vulnerability for the development of PTSD whereas other attachment styles may act as a protective factor to guard against the development of PTSD. In this paper, we examine attachment styles and PTSD in a group of security workers who experienced one or more traumatic events in the previous 12 months. We propose differences in PTSD between securely attached and insecurely attached security workers who experienced one or more traumatic event(s) in the previous 12 months. We assume the adult attachment style can be seen as a protective or risk factor against the development of PTSD.
2. Methods 2.1. Participants
Self report data were collected in 2004 from 81 male adults working as security workers for a security company in Belgium. In the past 12 months, all respondents were victimized at least once from a serious work-related life event. The candidate respondents were informed and instructed about the study and were invited to participate voluntarily in this
study. Respondents contained the
was married, 18% single, 9% divorced and 16% lived together without being married. All security workers had experienced a traumatic event in the past twelve months, such as shootings, hostage situations, and riots.
2.2. Measures
The Davidson Trauma Scale (DTS) provides a brief and accurate measure of PTSD symptoms. It is a 17 item self report scale and each item corresponds to a DSM-IV™ symptom of PTSD. Each symptom is rated in terms of frequency and severity. The DTS norms provide three subscale scores reflecting the three trauma symptom clusters in DSM-IV: intrusion, avoidance/numbing and hyperarousal. Participants indicated how often they had experienced each symptom with (0) not at all to (4) everyday.
A summated score for the frequency of all of the symptoms was utilized as a measure of PTSD (Davidson, Book, Colket et al., 1997; Davidson, 2004). The DTS is designed to cover all types of traumatic event including accidents, combat, sexual assault, criminal assault, natural disaster, torture, burns, loss of property, near death experiences, and bereavement. The scale demonstrated good test-retest reliability (r = 0.86), and internal consistency (r = 0.99). Concurrent validity was obtained against the SCID, with a diagnostic accuracy of 83% at a DTS score of 40. Good convergent and divergent validity were obtained.
The DTS showed predictive validity for response to treatment, as well as for being sensitive to treatment effects (Davidson et al., 1997; Davidson, 2004). We can conclude that the DTS shows good reliability and validity, and appears to be a scale which is particularly suited to assess symptom severity and
treatment outcome and screening for the likely diagnosis of PTSD.
The Relationship Questionnaire (RQ) is a single item measure made up of four short paragraphs, each describing a prototypical attachment pattern (secure, fearful, preoccupied or dismissing) as it applies to close adult peer relationships. Participants were asked to rate their degree of correspondence to each prototype on a 7-point scale. These ratings (or "scores") provide a profile of individual's attachment feelings and behaviour.
The RQ can either be worded in terms of general orientations to close relationships, orientations to romantic relationships, or orientations to a specific relationship (or some combination of the above). The RQ was designed to obtain continuous ratings of each of the four attachment patterns, and this is the ideal use of the measure. However, if necessary, the RQ can also be used to categorize participants into their best fitting attachment pattern. The highest of the four attachment prototype ratings can be used to classify participants into an attachment category (Bartholomew, Horowitz, 1991; Griffin, Bartholomew, 1994).
3. Analysis
two groups (securely attached and insecurely attached security workers) and to examine whether PTSD symptoms differs significantly between securely attached and insecurely attached security workers. Thirdly, binary logistic regression analysis was used to estimate odds ratios for the four attachment styles to determine the unique contribution of
the differentiating variables in forecasting PTSD (binary dependent variable = PTSD or not). There were no assumptions with regard to the order of the independent variables, so in performing the analysis, a block entry of variables method was used.
4. Results
Table 1: Background variables for secure and insecure attached security workers:
Background variables Secure attached Insecure attached T-value and sig.
PTSD Mean SD Mean SD
Re-experiencing 6.50 8.25 12.64 9.91 -2.57, p<.01
Avoidant 7.90 10.94 15.28 13.78 -2.22, p<.05
hyper arousal 10.19 10.36 16.93 10.66 -2.64, p<.01
On the basis of K-Means Cluster Analysis, 37 respondents were classified as securely attached and 38 as insecurely attached. Six individuals couldn’t be involved in the study because of missing cases. Significant differences were found between secure and insecure attached security workers on the three PTSD symptom clusters of the DTS (Table 1). All p-values were less than the critical value (alpha set at .05). Since the test statistic is much larger than the critical value, we rejected the null hypothesis of equal population means and concluded that there is a (statistically) significant difference between securely attached and insecurely attached security workers regarding the three PTSD symptoms.
In a second step the four attachment styles were entered in a logistic regression model to examine the independent effect of each attachment style on PTSD. A DTS cut-off
point of 40 was used to classify a participant as suffering or not suffering from PTSD. From the 81 respondents 74 were included, seven individuals were excluded because of missing values. Forty one were diagnosed as PTSD and 33 were classified as not suffering from PTSD. The model classified correctly 74% suffering or not suffering from PTSD. A Cox & Snell R Square of.18 showed that the overall model explained 18% of the variance in PTSD. Only the preoccupied attachment style was significantly positively related to the dependent variable in the logistic regression model. We found an odds ratio of .39 for the preoccupied attachment style (p<.05) what means that the likelihood of developing PTSD is more than two times and a half higher for security workers with a preoccupied attachment style.
relationships. They often feel that others do not want to get as close as they would like. They also have less positive views about themselves and doubt their worth as a partner. People who are preoccupied with attachment obtain higher levels of emotions and impulsiveness in their relationships (Bogaerts, Kunst, Winkel, 2009). The preoccupied attachment style has also implications for treatment outcome of individuals with PTSD. Recently, Forbes, Parslow, Fletcher, McHugh and Creamer (2010) argued that the attachment style is known to be associated with psychopathology after a traumatic event and is probably a factor for treatment outcome.
The researcher examined in a treatment group of combat Veterans with PTSD the relationship between the specificity of the attachment style in relationship to treatment outcome. The preoccupied attachment style impedes recovery in group-based treatment for veterans with PTSD (Forbes et al., 2010).
5. Discussion
This study was conducted to determine whether an unsafe attachment style can be seen as a vulnerability factor in the prediction of PTSD. In this study, 81 security workers who suffered from a serious work-related event in the past 12 months were divided (via cluster analyses) into a secure and an insecure attachment group. Both groups were compared on their scores for the three PTSD symptom clusters (re-experiencing, avoidant and hyper arousal). Mean PTSD scores on the three clusters differentiated significantly between the two groups. Insecurely attached persons reported significantly more PTSD
symptoms than securely attached
respondents. Furthermore, attachment styles
were examined in their independent contribution to the prediction of PTSD. Only the preoccupied attachment style offered a significant contribution to the prediction of PTSD. The likelihood to develop PTSD was more than two and a half times more for preoccupied attached security workers than for the other attachment styles.
with the partner, environmental factors, risk and stress factors and the quality of coping mechanism.
The definition of a traumatic event in this study was undeniably subjectively classified, for participants were asked whether they had experienced a traumatic event during the past year. They were asked to describe the event in order to provide insight into their experiences.
6. Research perspectives
The development of PTSD symptoms is the result of complex intrapsychic and situational factors. More specifically, PTSD displays biochemical changes in the body and brain. Heide and Solom (2006) found out that long-term changes in the brain associated with child maltreatment include significantly smaller total brain and cerebral volumes. Most biological findings in PTSD are increased corticotropin-releasing factor concentrations, catecholamine depletion within the central nervous system, and reduced hippocampal volume.
Over the last 10 years, biological observations found that urinary and plasma cortisol levels are considerably lower in PTSD patients than in non-PTSD trauma survivors and normal controls. Furthermore, the circadian pattern of cortisol release from the adrenal glands follows a greater dynamic range in PTSD than in patients with major depression or in normal controls (Yehuda, 2001).
At this moment there are no published studies looking at the involvement of the amygdale, yet preliminary evidence suggests that people with PTSD do have memory deficits resulting from dysfunction of this structure (Isaac, Cushway, Jones, 2006). Adami, Konig, Vetter et al. (2006) found preliminary evidence that
the amygdala-hippocampal region is functionally and morphologically involved in the aetiology op PTSD.
The last two decades, since the introduction of PTSD into the DSM-III (APA, 1981), considerable research has demonstrated the efficacy of pharmacological and several cognitive-behavioral therapy programs in the treatment of (chronic) PTSD. Eye movement desensitization and reprocessing and trauma-focused cognitive-behavioural therapy are both widely used and efficiently in the treatment of PTSD (Seidler, Wagner, 2006). Selective serotonin reuptake inhibitors, such as sertraline, paroxetine and fluoxetine are considered efficient first-line medication treatment (Robert et al., 2006). Finally, there is no evidence based research concerning the relationship between debriefing and PTSD among security workers. For other groups (e.g., police officers, fire-fighters) controlled and correlational studies have failed to demonstrate therapeutic effects of stress debriefings and some studies reported iatrogenic effects (Harris et al., 2002; Bootzin, Bailey, 2005).
Further research into psychotherapeutic, biological and pharmacological treatment is necessary to study the changeability of the adult attachment style and PTSD.
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