Scholarly Peer Reviewed Articles on Disorganized Attachment and Treatment Strategies

Introduction

Over the concluding decades, zipper theory (see BOX 1 for a brief description of attachment theory) has been applied to a lot of developmental and clinical fields, including substance use disorders (SUDs). A growing number of zipper-based studies have tried to contribute to the understanding of SUDs. In 2005, a first review tried to construction the field (1). It independent 2 chief questions:

1. Is there a link between zipper and SUD?

2. Is there a link between ane or several specific attachment patterns and SUD?

Additionally, it asked for the direction of these possible links, that is, for developmental pathways between attachment and SUD. It looked for differences betwixt different historic period groups, between users of dissimilar substances, due to dissimilar levels of severity of SUD (employ, abuse, addiction) and due to different comorbid psychiatric disorders. This offset review identified 12 studies published between1990 and 2005. Results indicated a link betwixt insecure attachment and SUD, but they were inconclusive with regard to any other question. In the calorie-free of a growing torso of research, this article is going to readdress the questions of the 2005 review. It tries to give a concise overview over what nosotros know today nearly individual patterns of attachment among consumers of psychotropic substances. This might help to prepare the ground for a possible later integration of attachment in a multifactorial model of SUDs [run into Due west and Dark-brown (2), for an overview over habit theories] and in the treatment of SUDs. Note that this review will not cover the topic of addictive behaviors such equally gambling disorder or internet gaming disorder. And it will non cover the vast body of research on zipper in children of substance-abusing parents. This article will offset requite a theoretical introduction and sum upwardly what we know from earlier reviews. It will then move on to methodological issues and to a review of the testify represented in empirical studies today.

Insecure Attachment and Substance Use Disorders

Human beings who do not experience a sufficiently secure base develop insecure patterns of attachment, including negative IWMs of themselves and others, and negative expectations with regard to relationships (this includes therapeutic relationships, making it more than hard to establish a treatment alliance). Although insecure attachment is not a pathological status in itself, it is related to mental disorders. Its ratio in clinical samples is 86%, in dissimilarity to 42% in the general population (ix). Information technology is seen every bit an important risk gene not merely for SUD, but likewise for mental disorders in general (x). With increasing insecurity, individuals will face more than difficulties in regulating emotions and stress. This regulation will not part either with the assistance of attachment figures or with the use of IWMs. At the same time, insecure individuals will face difficulties in forming and maintaining relationships with others. Psychotropic substances then might become attractive as i fashion to "self-medicate" zipper needs, to regulate emotions, to cope with stress, and to supersede relationships (8, 11, 12). Earlier reviews have shown cross-exclusive evidence for a link between insecure attachment and SUDs (one, 8, 10, 13, 14). Additionally, they have reported preliminary longitudinal evidence for insecure attachment being a risk cistron for later substance corruption. This review will look for a replication of the general link and for more longitudinal information.

Box 1. What is attachment?
"Zipper is a motivational, behavioral, and interactional system that provides security for young offspring in a variety of species. The attachment organisation regulates distance and closeness of parents (or 'zipper figures') and children. The child will seek closeness to his/her parents whenever he/she feels in danger. Ideally, parents volition then comfort the child, at-home him/her down, and give him/her a rewarding feeling of security. This feeling of security or 'secure base' created in early on zipper experiences helps the child to regulate his/her emotions and is an important pace on the manner to acquiring own coping strategies when facing fright or distress. Against the properties of a 'secure base', the child can explore his/ her surround (3–5). At the same time, secure zipper is the base for an exploration of his/her own inner earth and that of others, that is, for the ability to 'mentalize' and to gain a coherent picture show of mental processes (6). Over fourth dimension, experiences with attachment figures are internalized. The child develops cognitive representations ['inner working models' ('IWMs')] of himself/herself and of his/her attachment figures. If positive IWMs are developed, other persons than the original attachment figures tin also become a secure base of operations. Additionally, positive IWMs make it possible to regulate melancholia states autonomously without depending on another person. In this sense, 'secure zipper liberates' (7)." (viii, p. 305).

Although most theoretical and empirical work has focused on insecure attachment as a risk factor for the development of SUDs, it is likely that substance abuse has an upshot on zipper, besides. The consequences of substance abuse are a host of well-known developmental risks and neurological impairments (xv). From an attachment perspective, four mental processes might exist direct afflicted by substance abuse. Showtime, exploration of the surroundings is reduced or distorted, or risks are taken that would never have been taken in a state of sobriety (16). 2nd, mentalization, the exploration of the inner, mental world of oneself and others is reduced (17). This might even exist a possible motivation for substance corruption: nonmentalization and nonperception of distress and painful memories. Third, age-appropriate experiences in relationships oftentimes are inhibited or even prevented (xviii). Fourth, affect regulation and reward might exist replaced by substance abuse (19). Further indirect show comes from the host of studies in samples of substance-abusing parents. These parents are hardly able to establish secure attachment relationships with their offspring (20). In sum, substance abuse might well have a negative impact on the ability to attach and form close relationships. Earlier reviews failed to provide empirical evidence regarding this bespeak. This review will wait for longitudinal evidence for an impact of substance abuse on attachment.

Individual Patterns of Attachment and SUDs

Zipper theory describes different patterns, which are based on the specific experiences in zipper relationships. They involve different levels of security, different strategies of coping with negative experiences in close relationships, and different ways of regulating negative affect and expressing attachment needs. Individuals with preoccupied (sometimes called ambivalent/enmeshed/broken-hearted) patterns use affectively hyperactivating strategies and are seeking closeness to important others. They are preoccupied with their own distress and the availability of attachment figures. Individuals with dismissing–avoidant strategies, on the other hand, tend to use distancing, affectively deactivating strategies. They defensively turn their attending away from their emotional distress and their attachment figures. A third group of patterns is characterized by a lack of functioning coping strategies and the highest take a chance for the development of severe psychopathology: disorganized patterns of attachment. These are associated with parental psychopathology (SUDs amid others), with traumatic experiences (sexual abuse and maltreatment) likewise equally loss and neglect (21). While zipper originally described these patterns equally categories, a dimensional approach seems to represent the existing data more precisely (22). Effigy 1 presents a two-dimensional model of zipper patterns, trying to integrate the different constructs. Note that this model is just meant to give a crude orientation. The dimension secure–insecure is well established. Specially the definition of secure zipper is common ground. However, there are very different concepts describing the insecure stop of this dimension (disorganized, unresolved, fearful–avoidant, hostile–helpless). Although these concepts are dissimilar, they share the lack of adaptive coping strategies and a high take a chance for developing mental disorders. The 2d dimension is generally labeled "coping fashion" with preoccupied patterns on the left-mitt side and dismissing–avoidant patterns on the correct-hand side. Two-dimensional models of attachment patterns often utilize the dimensions of anxiety and abstention (23). This is a cistron solution that is rotated past 45° to the i described here (Figure one). For more detailed discussions of these concepts, meet Ravitz et al. (24) and Shaver and Mikulincer (22).

Effigy 1 Two-dimensional model of attachment.

Evidence presented in before reviews was inconclusive with regard to specific patterns of attachment. While some studies pointed to more than avoidant patterns in substance abusers (1), others indicated links with different patterns (viii, 10, 14). At that place had non been whatever longitudinal information on possible developmental pathways from specific patterns toward SUD. The relation between specific patterns and SUD is still an open question to be addressed in this review.

The Apply of Different Substances

According to the "self-medication hypothesis" (12), the abuse of specific substances might exist an endeavour to cope with specific forms of emotional distress. For example, the abuse of stimulants might exist linked to more hyperactivating, closeness-seeking zipper strategies, while the use of sedatives might be linked to deactivating, distancing strategies. Post-obit the opioid arrears hypothesis (25; see Box 2), abuse of heroin and other opioids might exist linked to extremely insecure attachment.

Box 2. Neurobiological research and the reward–deficiency hypothesis.
Neurobiological inquiry has focused on motivational processes of both attachment and substance corruption (26–29). Both are transmitted by the same mesolimbic and mesocortical circuits, and for both, dopamine, endorphins, oxytocin, and vasopressin play important roles. This line of enquiry mainly relies on the reward–deficiency hypothesis of addiction (xxx, 31), assuming that psychotropic substances can substitute other "scarce" sources of advantage. Attachment theory posits that insecure individuals take non sufficiently experienced the advantage of a secure base. Their advantage organization tends to be comparatively conditioned to satisfaction by social contact (29). Based on a host of animal studies on endorphins and opioids, Trigo et al. (25) have operationalized reward–deficiency equally an opioid deficit. They assume that insecure attachment and insufficient workout to advantage by social contact lead to a lack of endorphins in the VTA. As a consequence, dopaminergic advantage processing in the limbic organization cannot be released. This leads to a advantage deficiency and increases the risk for addictive behaviors. Especially opioids might be a potent substitute for lacking attachment strategies. Recently, Alvarez-Monjaras et al. (nineteen) have presented a multifactorial developmental model of zipper and addiction. The model basically assumes a functional interchangeability of attachment processes and substance use. According to this model, positive attachment experiences and secure patterns strengthen reward from social contact and subtract the risk for addictive behaviors. Negative attachment experiences and insecurity, on the other mitt, pb to insufficient reward from social contact and to a heightened risk to replace it with addictive behavior (19).

Despite some information from studies in alcohol and heroin using samples, before reviews have been inconclusive. The question of attachment-related differences between users of different substances will have to exist addressed in this article.

Severity of Substance Utilise

In theory, more than insecure individuals face a higher risk for developing SUDs. This does non necessarily imply that they develop more severe forms of SUDs. But if substance abuse impaired the attachment system, severity of abuse might be linked to severity of harm. The review by Iglesias et al. (xiv) reported some evidence for a deviation between experimental substance use and substance corruption in adolescent samples. The prove in earlier reviews is limited, so it is nevertheless an open question: Does severity of substances use (apply, abuse, addiction) make a departure with regard to zipper?

Comorbid Psychiatric Disorders

Comorbid psychiatric disorders are common in samples of substance abusers. Insecure attachment is not exclusively related to SUDs but to psychiatric disorders in general (10). Comorbidity might well exist an important mediator of findings in this surface area. At the same time, it makes research very circuitous, because individuals with different comorbid disorders might use unlike substances for dissimilar reasons.

Schindler et al. (ane) presented some limited evidence for dissimilar patterns of zipper in substance-abusing adolescents with dissimilar comorbid disorders. However, the question of the part of comorbid disorders in the relation between attachment and SUDs has to be readdressed.

Age: Substance Corruption in Adolescence Vs. Adulthood

The use and corruption of psychotropic substances usually begin and peak in adolescence. It is a crucial phase for the development of SUDs (xi). At the aforementioned time, adolescence is important in the evolution of attachment. It is a transitional period when autonomy from parents, from the "secure family base of operations," is adult (32, 33). This might advise a closer relation between attachment and SUD in adolescence than in machismo. 2 earlier reviews have discussed these complex topics in detail (viii, 14) but have non presented whatsoever information comparison adolescent and adult samples. This review volition look for historic period-related effects with regard to zipper and SUDs.

Methods

Literature for this review was scanned in PubMed/MEDLINE, Web of Science, PsycARTICLES/PsycINFO, PSYNDEX, EMBASE, and CINAHL databases for "all years" with a concluding update on Apr 4, 2019, using the following keywords: "attachment," "zipper theory," "patterns of attachment," "substance utilise disorders," "substance abuse," and "habit." Additionally, references in manufactures and presentations were tracked. Criteria for inclusion were original empirical studies; basic research standards are met (which was not the case in studies earlier than 1990); use of validated measures of zipper; study based on zipper theory; focus on zipper of substance using individuals (this excluded studies focusing on children of substance users); and cess of substance use, abuse, or addiction. Five hundred twoscore-vi publications were scanned. After removing duplicates and studies not coming together the criteria, we included 37 original studies on attachment and SUD and 1 quantitative meta-analysis. Iii of the original studies were longitudinal. Two further studies had a longitudinal design, but reported only cantankerous-sectional data for the question at hand. Meet Figure 2 for a flowchart of the option procedure.

Figure two Flowchart study selection.

Although we only included studies grounded in attachment theory, the apply of different zipper measures makes results difficult to compare results. Boosted methodological bug arise from flaws in the cess of substance abuse and in sample selection. Samples were very heterogeneous, including different substances and unlike stages of severity. Most studies relied on cocky-report measures of substance utilise, with urinalyses or similar physical measures being rare.

Measures of Zipper Patterns

Attachment research has developed dissimilar measures. These share the basic distinction between secure and insecure zipper, but differ in the definition and labeling of specific patterns. While attachment interviews appraise attachment representations, divers as the land of mind with regard to early attachment experiences, self-report questionnaires assess zipper styles, defined as experiences and behavior in shut relationships (including romantic relationships). Although attachment theory assumes that these patterns develop in early babyhood, both types of measures assess the electric current state of the attachment organisation. Zipper questionnaires and interviews prove moderate correlations. The bulk of studies use self-reports, which are seen as "surface indicators" of attachment representations (22, 24). The Developed Attachment Interview (AAI) (34) is a semistructured interview with four categories: secure–autonomous, preoccupied, dismissing, and unresolved. The category "hostile–helpless" was added later on to depict special patterns mainly occurring in clinical samples (35). The Developed Attachment Projective (AAP) (36) is a projective test designed to produce narratives that can be categorized in the same way as the AAI. The Hazan and Shaver Self-report (HSSR) (37) is a elementary measure consisting of cursory descriptions of three attachment styles with respect to experiences in romantic relationships. Attachment styles are called secure, broken-hearted–clashing, and avoidant. Note that abstention is rather defined as fearful–avoidance in the Bartholomew model (high insecurity, no coping) and not as dismissing avoidance in the AAI. The Adult Attachment Scales (AAS) (38) is a multi-particular calibration based on the HSSR. It assesses secure, anxious, and avoidant zipper styles. Note that broken-hearted zipper here is defined as the loftier end of the anxiety scale. Bartholomew and Horowitz (23) adult a model of four zipper categories, based on positive and negative internal working models of the cocky and of others. Bartholomew differentiated between two avoidant categories: fearful–avoidant (co-ordinate to the HSSR) and dismissing–avoidant (according to the AAI) (Figure 1). Based on this model, several self-study measures such equally the Relationship Questionnaire, the Human relationship Calibration Questionnaire (39), the Experiences in Shut Relationships (twoscore), and an Attachment Interview take been adult (23).

Results

Insecure Attachment and SUDs

All studies in this review report a link between insecure zipper and substance abuse or addiction (Table one). Secure zipper was typically found in healthy controls in all studies including a control group. Cooper et al. (41) additionally showed a relation with experimental substance utilise in adolescence.

Table 1 Studies on zipper and substance use disorders.

Three longitudinal studies bespeak that attachment in an before historic period has an bear upon on later substance abuse. Branstetter et al. (44) demonstrated that securely attached adolescents at age 14 years consumed fewer substances at age 16 years. Danielsson et al. (77) showed that zipper security at age xiii years prevented heavy drinking episodes at age 15 years. In a study by Zhai et al. (76), insecure attachment at age 10 to 12 years led to dysregulation at age 16 years and substance abuse at age 22 years. In a meta-analytic adding, Jordan and Sack (78) calculated that secure attachment decreases the risk for substance abuse past odds ratios ranging from 0.60 to 0.lxx. Thus, the risk for substance abuse is about one-third lower for securely attached adolescents.

The impact of substance abuse on attachment security has been studied less oft. Unterrainer et al. (57) found such an touch on with a stiff neurotoxic outcome in a clinical written report of long-term addicts. Nonclinical studies have been less conclusive (79). A contempo quantitative meta-analysis of prospective longitudinal studies (lxxx) analyzed 34 original studies with as many as 56,721 participants. Studies mainly investigated community or college samples with a mean age of xv years (range, seven–30 years); they covered a mean period of fourth dimension of 3.8 years, and they mainly used attachment cocky-reports. The analysis yielded meaning prospective relations in both directions with a significantly stronger effect of insecure attachment on substance abuse than vice versa.

Individual Patterns of Attachment: Styles and Representations

Data from longitudinal studies do not provide whatever information almost different developmental pathways of individuals with specific patterns of attachment. Notwithstanding, the last three decades have seen a substantial growth of cross-exclusive studies. Eight studies were carried out with the AAI/AAP. Six used the HSSR, and another six the AAS. Fourteen studies used measures based on the Bartholomew model. Three studies used other measures Attachment and Clinical Bug Questionnaire, Youth Attachment to Parents Scale, Inventory of Parent and Peer Zipper (ACIQ, YAPS, IPPA). Earlier describing results in detail, hither is a cursory overview:

● AAI/AAP studies mainly show dismissing and unresolved representations.

● In HSSR studies, fearful attachment was the about frequent style.

● AAS studies mainly report anxious attachment styles.

The majority of studies used the Bartholomew model point toward fearful–avoidance, with some testify for a link with the anxiety dimension.

AAI/AAP Studies

A small German written report (43) establish dismissing and unresolved representations in boyish drug addicts using multiple substances. Two other studies examined samples of adolescents in psychiatric inpatient treatment with SUD and other psychiatric diagnoses. Rosenstein and Horowitz (50) constitute partly dismissing and partly preoccupied representations in substance abusers with different comorbid disorders. Allen et al. (51) written report a relation betwixt "hard drug use" and dismissing zipper. Although this study had a longitudinal pattern, results concerning attachment and SUD were cantankerous-sectional. Studies in adult samples found hostile–helpless representations (35, 45) among African American mothers in methadone maintenance treatment, a general link to insecurity in a sample of adults who had been adopted in childhood (46, 47) and unresolved representations among expecting parents (48), among substance-abusing psychiatric inpatients (49), and among adult drug addicts (using the AAP; 42).

HSSR Studies

HSSR studies mainly examined nonclinical samples. While a high-school written report reported a link between anxious attachment and "problematic" substance corruption (41), the bulk of substance abusers in a big representative US-wide sample described themselves as avoidant (53). So did the majority of "heavy drinkers" in college (54) and young adult samples (55), as well as adult long-term heroin addicts in State of israel (52).

AAS Studies

About AAS studies report broken-hearted attachment in substance-abusing college students (60), in alcohol abusers in Korea (59), in alcohol addicts (61), and heroin addicts (57). An exception is the study past Durjava (56), which reports heightened scores on all insecure scales in heroin addicts.

Studies Using Measures Based on the Bartholomew Model

Studies in college samples mainly found links between alcohol corruption and fearful–avoidant patterns, while preoccupied and dismissing patterns occurred less often (68, 73, 74). The same constellation of patterns were found in clinical samples of substance-dependent individuals (18, 62, 64, 72). In samples of heroin addicts, fearful–avoidant attachment was the principal blueprint (i, 52, 71), while alcohol addicts showed either preoccupied (67) or generally insecure attachment (65, 69, 70). A written report in adults in primary care found hazardous drinking to be linked to the anxiety dimension (63). Jenkins and Tonigan (66) constitute elevated attachment feet in an Alcoholics Bearding (AA) sample. Although this report had a longitudinal design, results concerning attachment, and SUD were cross-exclusive.

Dissimilar Substances

Only two studies compare users of different substances systematically. Zeid et al. (75) did non find any differences betwixt booze and opiate addicts. In contrast to this written report, Schindler et al. (71) did find significant differences betwixt heroin, ecstasy, and cannabis users and nonclinical controls. While heroin addicts were mainly fearful–avoidant, controls were mainly secure, and cannabis abusers tended to be dismissing–avoidant. Ecstasy (MDMA) abuse was related to insecure attachment, but not to a specific attachment design.

Studies in specific groups provide some additional information well-nigh heroin, alcohol, and cigarette smoking. With regard to heroin addiction, they indicate fearful–avoidance (one, 52), as well equally hostile–helpless representations in the AAI (45) and insecurity in general in the AAS (56). Studies in samples of alcohol users also showed avoidant and highly insecure patterns, but higher rates of preoccupied/ambivalent attachment (67) and a relation with the feet dimension, too (59, 61, 63, 66). The meta-analysis of Fairbairn et al. (lxxx) shows a shut relation between attachment-based emotion regulation and cigarette smoking.

Severity of Substance Use

A comparison of studies in clinical versus nonclinical samples does non show whatsoever systematic differences in attachment patterns. Particularly alcohol apply, abuse, and habit have been studied repeatedly without finding different patterns of attachment. However, results testify a correlation between severity of opioid addiction and zipper insecurity. Opiate addicts in Islamic republic of iran were more insecure than nonaddicted opiate users (58). Severity of heroin employ correlated with fearful–avoidant attachment (1, 62).

Comorbid Psychiatric Disorders

Rosenstein and Horowitz (50) study mainly dismissing classifications in boyish substance abusers with comorbid conduct disorders but partly dismissing and partly preoccupied classifications in those with affective disorders. In a study of Schindler and Sack (64), comorbid patients with SUD and borderline personality disorder (BPD) were similar to other BPD patients in several psychiatric measures, only closer to SUD patients with regard to attachment. They were more than avoidant and less preoccupied than other BPD patients. With regard to PTBS, 3 studies institute a link betwixt SUDs and unresolved attachment (43, 48, 49), while two other studies did not detect this relation in adolescent samples (l, 51).

Age: Boyish vs. Developed Samples

The meta-analysis by Fairbairn et al. (80) shows a closer relation betwixt insecure attachment and substance abuse in adolescents than in adults. In AAI studies in adolescent samples, dismissing attachment seems to be the most frequent representation, while adult samples mainly showed unresolved and hostile–helpless representations. Other studies exercise non signal any systematic differences betwixt adolescent and developed samples.

Discussion: Implications for Research and Handling

Insecure Attachment and SUDs

A host of cantankerous-exclusive studies consistently replicated the finding of a general link between insecure attachment and SUDs. Secure zipper is only occurring in experimental substance users and in good for you controls. Evidence from psychological studies is in tune with neurobiological findings. Longitudinal studies and meta-analyses indicate that secure attachment is a protective gene against substance abuse, and insecure zipper is a risk factor for substance corruption. Taken together, the general link between insecure attachment and SUDs today is well established, and there is moderate to strong evidence for the assumption of insecure attachment being a risk gene for SUD.

Additionally, there is moderate meta-analytic longitudinal prove for a negative bear upon of substance abuse on zipper. This upshot might be linked to the severity of substance abuse. The study by Unterrainer et al. (57) suggests that it might be, at to the lowest degree in office, an unspecific effect of neurotoxic impairments caused past substance corruption. The negative psychological effects described in a higher place might accept an affect, too, but in that location is no direct evidence in the studies reviewed. Indirect evidence comes from parenting studies, showing that substance abusers take serious problems to provide secure attachment for their offspring (20). In the light of existing data, a vicious circumvolve between insecure zipper and substance abuse seems likely. But we will need more than longitudinal studies to gain a more detailed picture of this interaction. Studies volition have to utilise psychological also as neurobiological measures to control for possible confounds.

Different Patterns of Attachment

It is more difficult to summarize the results of the 37 studies analyzing attachment patterns.

Their results mainly betoken toward very insecure patterns (unresolved–disorganized and hostile–helpless in the AAI, fearful–avoidant in the Bartholomew model). This supports the hypothesis of substance abuse as a substitute for scarce attachment strategies. Only there is some evidence for other patterns every bit well, with avoidant patterns occurring more frequently than preoccupied or anxious ones. We all the same lack longitudinal data on developmental pathways from specific patterns toward SUD. Additionally, the selection of very unlike samples and the use of different measures make it hard to draw conclusions. Differences between studies using different measures suggest a methodological bias. We need studies comparing different measures in one sample to discern these furnishings. Even so, a lot of studies written report different patterns within one sample, assessed with 1 measure out. This suggests that different patterns are linked to SUD. From an attachment theory signal of view, it seems likely that individuals with unlike patterns of attachment use psychotropic substances for dissimilar reasons. Individuals with preoccupied attachment might use substances to minimize social fears and to make it easier to get in touch with others. Individuals with avoidant patterns might employ substances to avoid feeling negative emotions, zipper needs, and loneliness. Individuals with disorganized patterns might use substances to cope with fear and posttraumatic symptoms. Future research will have to consider different and complex pathways in a longitudinal pattern.

Different Substances

Results from two systematic comparisons of users of dissimilar samples are inconclusive. There is some evidence for a link between heroin use and extremely insecure patterns. Although studies used different measures, all found these extremely insecure patterns, ranging on the level of disorganization (Figure 1). This is in tune with the endorphin-deficit hypothesis (25), assuming that opioids might be especially bonny for highly insecure individuals. Preliminary data on alcohol abuse point to different patterns. Studies found relations with avoidant and highly insecure as well as preoccupied/ambivalent patterns. Information technology seems possible that alcohol abuse tin have different functions. Information technology might be used to reduce social fears and support closeness seeking in preoccupied individuals. Avoidant or fearful individuals, on the other hand, might utilise higher doses to avoid contact and deactivate emotions. The only report exploring ecstasy (MDMA) expected a relation with preoccupied attachment only plant more often than not insecure patterns. The "entactogenous" result of ecstasy does not seem to be related to closeness seeking in the sense of zipper. Meta-analytic information point toward a relation betwixt nicotine and affect–regulation in adolescence. In mainly nonclinical samples, cigarettes might be the drug of choice for those with insecure zipper and issues to regulate emotions. Enquiry on different substances is still fragmentary. Several important substances (due east.g., cocaine, benzodiazepines, methamphetamines, etc.) have non even been studied. Systematic comparisons are rare. Although it is besides early to report any definite relations, there does not seem to be a full general link between substance abuse and a single specific pattern of zipper. This renders future research more complex, facing a diverseness of substances and patterns of consumption. We volition need more than systematic comparisons of different groups. Studies should include neurobiological information, considering different substance-related effects.

Severity of Substance Abuse

Data on the severity of substance abuse are inconclusive, too. Whereas a comparison of samples of alcohol abusers versus addicts did non show any systematic differences, three studies report a correlation between severity of opioid habit and attachment insecurity. This is in tune with theoretical models, and it might hint at the special role of opioids. Notwithstanding, we need more studies to depict conclusions.

Comorbidity

Studies have addressed depressive, anxiety, conduct, borderline, and posttraumatic disorders, only nosotros nonetheless lack knowledge from other of import fields such as psychotic or bipolar disorders. Some studies showed different attachment patterns in substance abusers with comorbid conduct versus melancholia disorders. Some other study reported differences betwixt borderline patients with or without SUD. Posttraumatic stress disorders are special because they are linked to the concept of unresolved zipper and because clinical SUD samples show high rates of traumatic experiences (81). All the same, existing information on unresolved attachment and SUD are inconclusive. We however lack systematic studies on the relations between SUD, trauma, and unresolved attachment. Results on comorbid disorders in general show their relevance and the complexity of possible interrelations betwixt zipper, SUDs, and comorbid disorders. But it is too early to draw any specific conclusions. Future enquiry in clinical samples volition generally have to accept comorbidity into account.

Historic period

Cross-sectional studies practise not indicate any systematic differences in attachment patterns betwixt adolescent and adult samples. The differences found in AAI studies are difficult to explain. However, meta-analytic findings of a closer relation betwixt zipper and SUD in adolescence are more conclusive and more than in tune with expectations. They underpin the importance of the developmental phase. Adolescence should be a focus of time to come research within a developmental framework. Considering of the significance of the family background, this research will take to include a family unit systems perspective (Table two).

Table ii Review: questions, results, and implications.

Implications for Treatment

Based on the results of this review, some implications for the treatment and prevention of SUD will be discussed. We still are at an early stage, defective an integration of attachment in a model of SUD, lacking treatment concepts, and clinical trials.

Results propose that handling approaches should consider insecure zipper in SUD patients. Since there seem to exist different types of insecure attachment, these should be assessed and get role of individual treatment planning in the same mode as data nearly consumed substances, level of severity, and comorbidities is used. Attachment theory stresses the therapeutic brotherhood as a means to develop more than zipper security. However, establishing such a relationship with insecure substance abusers is difficult. It will often crave specific date strategies, and it needs to be adapted to the private design of attachment. Fowler et al. (82) found college rates of handling retention in addicts with preoccupied patterns. Information technology seems to exist more difficult to institute a therapeutic human relationship with avoidant or unresolved individuals. Data evidence that substance-abusing patients with BPD are more avoidant and more difficult to attain for handling (64).

Abstinence is a precondition for most treatments and for forming a therapeutic relationship. From an zipper point of view, abstinence means that substance abusers have to exercise without their usual coping strategy, leaving them without any operation strategy. At the same time they are asked to open up to others, a subjectively unsafe step, because negative human relationship expectations. Then therapists need to monitor their patients' limited ability to become and stay in touch on. From this perspective, relapses and treatment dropouts can be seen as avoidance of relationships.

Attachment-based approaches of individual handling could be adopted for the treatment of SUD. To appointment, the most promising approach is mentalization-based therapy (MBT) (6). MBT is fostering the ability to mentalize, that is, to explore inner states of oneself and others. Preconditions of this power are abstinence and felt security. The trouble is that substance abusers normally do not experience secure at all when they reach abstinence. MBT for SUDs then has to have careful small steps, fostering security, keeping abstinence, and slowly exploring feelings and inner worlds. An ongoing RCT is currently evaluating MBT in a sample of opioid dependent adults in Sweden (17).

Longitudinal data show a bidirectional relation betwixt insecure attachment and SUDs. This might have implications for treatment as well every bit prevention. It might become a vicious circle worsening both problems and a very challenging job to intermission this circle. Treatment has to focus on two goals that might reinforce each other in a negative or in a positive mode. Quitting substance abuse will exist easier when attachment security is fostered. The development of security, on the other hand, will benefit from abstinence. Gidhagen et al. (62) showed that it is possible to arroyo both goals successfully. They found an increment in attachment security in the course of habit treatment.

The treatment of SUDs might assistance to preclude the development of fifty-fifty more insecure zipper. This should take a positive outcome on relationships of substance abusers, including caregiving relationships with their children. Attachment-based prevention programs for children of substance-abusing parents are among the most elaborated and best evaluated approaches in the field (20). With regard to the prevention of SUDs, results suggest that fostering attachment security in childhood and boyhood might be effective. The importance of adolescence in the development of both attachment and SUD calls for early interventions designed for this age group. Among other things, this will need a family systems framework [Lewis (in this Frontiers Research Topic)]. Family treatments requite a chance to treat attachment-related disorders in the context in which they take developed. Family therapy approaches for adolescent substance abusers are among the best evaluated treatments (83, 84). To appointment, there are two explicitly zipper-based approaches, zipper-based family therapy (85) and mentalization-based family unit therapy (MBFT) (86). Although neither of these focuses on SUDs, it seems possible to integrate attachment-focused work into family therapy approaches for SUDs (87).

Finally, attachment research has stimulated the search for new medications, pointing toward the importance of oxytocin. This substance is now considered a promising therapeutic agent for alcohol utilise disorders (88).

Strengths and Limitations

This review has tried to requite a concise overview over 30 years of research in the field. Since 2005, the number of studies has tripled, providing strong evidence for the general link between attachment and SUD. Meta-analytic and longitudinal evidence shows the interaction between zipper and SUD. Although results are all the same inconclusive in many regards, they indicate the demand to differentiate between different patterns of attachment, different substances, comorbidities, and historic period groups. Results show the potential relevance of attachment inside a multifactorial model of SUDs. But in that location will still be a lot of theoretical and empirical work to be done to integrate it into a curtailed model. Methodological problems in the assessment of attachment and substance abuse limit comparability. There is a tendency in many studies to focus on attachment as a single variable and to condone its context and possible confounds. Future enquiry volition take to compare different groups of substance abusers systematically, including severity of substance utilise and comorbid disorders, linking psychological and neurobiological measures. We volition need more than longitudinal studies covering longer periods of time to completely sympathize the developmental pathways from zipper to SUDs. This review has not considered family systems of substance abusers or preventive aspects for children of substance-abusing parents. We will have to move to the level of systems and integrate family contexts into the study of attachment, linking attachment representations with relationship behavior and substance abuse.

Author Contributions

The author confirms being the sole contributor of this work and has approved it for publication.

Conflict of Interest

The author declares that the enquiry was conducted in the absence of any commercial or financial relationships that could be construed equally a potential disharmonize of involvement.

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