The association between insecure attachment styles, dissociation and PTSD symptoms: a systematic review

A associação entre estilos de apego inseguros, dissociação e sintomas de TEPT: uma revisão sistemática

ABSTRACT

OBJECTIVE:  To investigate the relationship between insecure attachment, PTSD, and dissociative symptoms.

METHODS:  We conducted a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) searching electronic databases including ISI Web of Science, Scopus, PubMed, and PTSD Pubs and nine observational studies were included. Our systematic review expands the literature by being the first to examine attachment typologies, including unresolved/disorganized attachment and dissociation symptoms in their relationship to PTSD symptoms.

RESULTS:  Our results demonstrate that unresolved/disorganized attachment is significantly and positively associated with PTSD and dissociation symptoms.

CONCLUSION:  This highlights the importance of assessing attachment types, more specifically, the unresolved/disorganized style, in conjunction with dissociative and PTSD symptoms, beyond simply investigating trauma history.

KEYWORDS
Insecure attachment; Parental bonding; Posttraumatic Stress; PTSD symptoms; Dissociative symptoms

RESUMO

OBJETIVO:  Investigar a relação entre apego inseguro, TEPT e sintomas dissociativos.

MÉTODOS:  Realizamos uma revisão sistemática da literatura seguindo as diretrizes PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), com a busca nas bases de dados eletrônicas como ISI Web of Science, Scopus, PubMed e PTSD Pubs. Nove estudos observacionais foram incluídos. Nossa revisão sistemática amplia a literatura ao ser a primeira a examinar tipologias de apego, incluindo apego não resolvido/desorganizado e sintomas dissociativos, em sua relação com sintomas de TEPT.

RESULTADOS:  Nossos resultados demonstram que o apego não resolvido/desorganizado está significativamente e positivamente associado a sintomas de TEPT e dissociativos.

CONCLUSÃO:  Isso destaca a importância de avaliar os tipos de apego, mais especificamente o estilo não resolvido/desorganizado, em conjunto com sintomas dissociativos e de TEPT, além da simples investigação do histórico de trauma.

PALAVRAS-CHAVE
Insecure attachment; Parental bonding; Posttraumatic Stress; PTSD symptoms; Dissociative symptoms

1. INTRODUCTION

The dissociation is associated with greater severity of PTSD symptoms¹ and occur in the impair integration and consolidation of traumatic events²,³, ⁴. When the integration fails, it promotes a psychological split of contextual and conceptual memories⁵ that increases the disconnection with safe reality, and consequently, the PTSD symptoms. The psychological split is especially harmful when trauma occurs during early developmental stages⁶ through situations of developmental trauma like abuse, neglect, exposure to domestic violence, parental separation, or unstable caregiving. Also, during childhood, children develop attachment styles. The attachment styles moderate the vulnerability to PTSD and dissociation⁷,⁸ and predicts greater severity of these symptoms⁹,¹⁰. Nonetheless, the relationship between PTSD and dissociative symptoms is still unclear.

Attachment theory¹¹ posits that early attachment figures function as a secure base. When there are no potentially traumatic events between the child and the attachment figure, the child typically explores the environment and returns in search of safety and emotional regulation. Currently there are four main attachment styles: one secure and tree insecures. The insecure attachment are anxious, also called ambivalent, avoidant¹² and disorganized¹³. Anxious and avoidant attachment styles, although maladaptive, maintain coherence with "organized" strategies of proximity to caregivers¹⁴. In contrast, disorganized attachment in children reflects a breakdown in these strategies.

To date, no systematic review has been identified in major scientific databases that examine the association between insecure attachments, including disorganized attachment, PTSD symptoms, and dissociation in adults. The present study aims to address this gap by conducting a systematic review of evidence on the associations within this relationship.

2. METHODS

2.1 Search Strategy

We conducted a systematic literature review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines¹⁵. Searches were performed in the following eletronic databases: ISI Web of Science, Scopus, PubMed, and PTSD Pubs with no restrictions on language or publication date. The search was conducted on May 8, 2025, using the following search terms: ("Posttraumatic Stress" OR PTSD OR PTSS) AND (attachment OR "parental bonding") AND (Dissociati*). The asterisk indicates that all terms starting with these roots were included. The advanced search was performed across all topics.

The abstracts of all identified studies were screened, and articles that did not meet the eligibility selection criteria were excluded. Full-text articles were then retrieved and assessed for inclusion. The study selection process is detailed in the flowchart presented in Figure 1.

Figure 1
PRISMA diagram for systematic review.

Figure 2
Risk of bias graph

Figure 3
Risk of bias summary

Two researchers conducted a blinded and independent review (T.R. and J.B.), and their results were compared. Any disagreement was resolved by a senior researcher (H.S.). Data extraction was performed by the first author (T.R.). The review protocol was registered in PROSPERO (CRD42024611063).

2.2 Selection of studies

A total of 636 studies were assessed. After removing 427 duplicates, 209 studies were excluded based on title and abstract screening. Subsequently, 24 full-text articles were assessed for eligibility, and nine observational studies that met the inclusion criteria were included in the final review (Figure 1).

2.3 Definitions, Inclusion and Exclusion Criteria

We used Population, Exposure, Comparator, and Outcomes (individuals exposed to trauma, of both sexes, aged 18 years or older. Exposure (E): Insecure PECO) framework¹⁶ to formulate inclusion criteria for observational studies: Participants (P): Adults and elderly attachment styles. Comparator (C): - Outcome (O): Dissociative and PTSD symptoms.

Included studies investigated the relationship between attachment styles in adult PTSD patients and dissociative symptoms using observational designs. Studies were excluded if they involved animal models, children or adolescents, review articles, meta-analyses, randomized controlled trials, case series (N < 5), naturalistic studies, book chapters, dissertations, or theses.

2.4 Risk of Bias Assessment

After the search, we assessed the methodological quality of the selected observational studies using the Cochrane ROBINS-E tool¹⁷. The ROBINS-E is designed to evaluate the risk of bias in observational studies, particularly cohort and case-control studies. The ROBINS-E tool was adapted solely by excluding items related to follow-up, as these were not applicable to the cross-sectional design. All other items in the evaluation were applied in all included studies. Two researchers (T.R. and H.S.) conducted a blinded independent data extraction and risk of bias assessment. Any disagreements were resolved by a senior researcher (M.M.).

2.5 Instruments for assessing PTSD and dissociative symptoms

All studies assessed dissociation and PTSD symptoms as separable, for this reason, in this systematic review, both dissociative symptoms and PTSD symptoms are treated as primary outcomes, examined independently in relation to insecure attachment styles.

2.6 Instruments for assessing attachment styles

Substantial methodological heterogeneity was observed across studies in terms of attachment measures. The included studies employed a variety of instruments to assess attachment styles, differing in both measurement approaches and interpretive frameworks. These instruments typically classify attachment either as fixed categories or along a dimensional continuum, for example, reflecting degrees of anxious and secure traits’¹⁸. Most instruments assessed adult attachment styles, except for the Adult Attachment Interview (AAI), which evaluates both adult attachment and broader familial attachment patterns. This heterogeneity complicates direct comparison across studies and likely contributes to variability in nomenclature in the observed associations with posttraumatic stress disorder and dissociation outcomes. We decided to quantify it according to the frequency of the associations, without establishing any equivalence based on similarities. All assessments were based on the theoretical framework of anxious, avoidant, and disorganized attachment styles¹², ¹³.

3. RESULTS

This systematic review found that insecure attachment, specially unresolved/disorganized attachment discourse suggests the association with the PTSD and dissociation symptoms. The sample size of all studies ranged from 27 to 296, with a total of 1,273 participants. All studies provided data on the mean age of participants, which ranged from 19 to 59.93. Of the nine included studies, four reported predominantly Caucasian ethnicity. The most frequent type of trauma was sexual abuse, with five studies and 415 participants, followed by Adverse Childhood Experiences (ACEs), with two studies and 370 participants, approximately 65% of the sample of studies included in this review. The remaining measures used and relevant details of the characteristics of the individual studies are reported in Table 1.

Table 1
Description of Observational Studies Investigating Attachment Styles, PTSD and Dissociative Symptoms.

Sample No.	Study (Year)	Study Design	Population, sample size	Mean Age	Proportion female/Ethnicity	Type of trauma	Diagnostic Dependent Variable (instrument)	Independent Variavel Evalued (instrument)	Attachment styles associated with PTSD and dissociation symptoms
1	(24)	Cross-sectional	n=73	59,93	26,03% women recruited in France	Cardiac risk	PCL-5 SDQ-20	ECR-12	Anxious
2	(23)	Cross-sectional	n=120	31,72	70,8 American indian women	Incarcerated women (53% sexual childhood abuse)	PCL-C DES	ECR-R	Insecure
3	(22)	Cross-sectional	n=19	43,9	35% Argentine women	Disappeared during the dictatorship	PCL-C DES	AAI	Unresolved/disorganized
4	(25)	Cross-sectional	n=296	31,51	58% women with BPD and ASPD recruited in England	Adverse childhood experiences	PCLS DES	ECR-R	Insecure
5	(26)	Cross-sectional	n=199	19	100% white American women	Adverse childhood experiences	PCL-C DES-II	RQ	Preocupied and fearful
6	(19)	Cross-sectional	n=27	33,02	100% women recruited in Switzerland	Sexual childhood abuse	PDS-5 DES	AAI	-
7	(20)	Cohort	n=80	36,56	93% withe American woman	Sexual childhood abuse	DSM-IV-TR MCMI-III DES DDI-S	ECR-12 AAI	Unresolved/disorganized
8	(21)	Cross-sectional	n=60	36,10	100% American women (43% white and 32% back)	Sexual childhood abuse	CAPS-IV TSI	AAI	Unresolved/disorganized
9	(27)	Cross-sectional	n=284	44,8	54,9% women recruited in USA	Sexual childhood abuse and terrorist attack	IES-R DES	ASQ	Insecure

• Note. Post-Traumatic Stress Disorder Checklist Scale (PCL-5), Post-Traumatic Stress Disorder Checklist Scale – Civilian version (PCL-C), Posttraumatic Stress Disorder Checklist Scale (PCLS), PTSD Diagnostic Scale for DSM-5 (PDS-5), The Life Events Checklist for DSM-5 (LEC-5), Clinician Administered Posttraumatic Scale for DSM–IV (CAPS), Impact of Events Scale-Revised (IES-R), Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition–Text Revision (DSM-IV-TR), Trauma Symptom Inventory (TSI), The PTSD-I Interview (PTSD-I), The Adult Attachment Interview (AAI), The Attachment Style Questionnaire (ASQ), Experiences in Close Relationship Scale-12 (ECR-12), Experiences in Close Relationships Scale – Revised (ECR-R), Relationship Questionnaire (RQ), Revised Adult Attachment Scale (RAAS), The Dissociative Experiences Measure Oxford (DEMO), Somatoform Dissociation Questionnaire (SDQ-20) for somatoform dissociation, Dissociative experiences scale (DES-II), Dissociative experiences scale (DES), Dissociative Disorders Interview Schedule (DDIS), *48% insecure fearful, 21% insecure worried and 10% dismissive. Grandchildren** Children

3.1 Risk of Bias Assessment

The overall risk of bias was determined following the guidance of the ROBINS-E tool: the highest level of risk assigned to any domain determined the overall risk. Regarding the methodological quality of the selected studies, two were classified as "high risk" for potential bias. One of the "high-risk" studies demonstrated "some concerns" in the domain "1. Risk of bias due to confounding" due to the lack of control for other types of trauma that might have occurred. Additionally, it was classified as "high risk" in the domain "7. Risk of bias in the selection of the reported result" because it claimed that the p-value for the PCL-C was significant and that a relationship existed between PTSD symptoms and disorganized attachment, despite the p-value not being significant (p = 0.083).

The other study was classified as "high risk" in the domain "1. Risk of bias due to confounding" for not controlling for other socio-demographic factors, such as previous trauma, the heterogeneity of study participants, and the nature of exposure to the terrorist attack. It was also rated "high risk" in the domain "2. Risk of bias in the measurement of exposure" for inadequately assessing participant's types of trauma, relying solely on a questionnaire developed by the authors that included three open-ended questions, potentially leading to recall bias. Seven studies did not present any risk of bias in any domain of this assessment. This systematic evaluation ensures a comprehensive understanding of the reliability and validity of the studies included in the review.

3.2 Association between attachment styles and PTSD and dissociation symptoms

The results were organized according to the instrument used in each study, preserving the original categories of attachment styles identified. Eight articles found a significant association between attachment dissociation PTSD association between attachment styles and PTSD and dissociation symptoms, three of which were unresolved/disorganized. One¹⁹ found no significant relationship between attachment styles, PTSD, and dissociation symptoms.

3.2.1 Adult Attachment Interview – AAI (George, Kaplan & Main, 1985)

The AAI was used in four studies. Of these, three²⁰,²¹,²² identified a significant association between PTSD and dissociation symptoms with the unresolved/disorganized attachment classification. One¹⁹ found no significant relationship between attachment styles, PTSD, and dissociation symptoms.

3.2.2 Experiences in Close Relationships (ECR) and Experiences in Close Relationships – Revised (ECR-R) (Brennan, Clark & Shaver, 1998)

The ECR and ECR-R scales were used in three studies, two of which²³,²⁴ found a significant association between higher levels of PTSD and dissociation with the insecure attachment style, without specifying subtypes. However, the sample²³ was represented by 69% anxious attachment. One²⁵ found a significant association only with PTSD symptoms, but not with dissociation symptoms.

3.2.3 Relationship Questionnaire – RQ (Bartholomew & Horowitz, 1991)

In the RQ, a study²⁶, found a significant association between increased PTSD symptoms and dissociation with the preoccupied and fearful attachment styles.

3.2.4 Attachment Style Questionnaire – ASQ (Feeney, Noller & Hanrahan, 1994)

In the ASQ, a study²⁷ found a significant association between PTSD symptom severity and dissociation with Adult Attachment, without specifying the specific subtype.

Across the reviewed studies, associations between insecure attachment and trauma and dissociation outcomes differed according to both the assessment strategy used and whether findings were evaluated in terms of frequency or consistency. Interview-based measures, particularly the Adult Attachment Interview, most frequently identified unresolved/disorganized attachment as associated with PTSD and dissociation, although this pattern was not observed uniformly in only one study. In contrast, self-report dimensional measures such as the ECR showed greater consistency, with anxious attachment associated with PTSD and dissociation whenever assessed. These findings underscore that frequency and consistency are conceptually distinct, as a pattern may appear more often across studies without being uniformly replicated; nevertheless, unresolved/disorganized attachment remained the most frequently associated with PTSD and dissociation symptoms pattern in the reviewed literature.

4. DISCUSSION

This review investigated the relationship between attachment styles, PTSD symptoms, and dissociation. Our results demonstrate that insecure attachment is significantly and positively associated with PTSD and dissociation symptoms best understood as context-specific of observational studies. This association between insecure attachment and PTSD symptoms is corroborated by systematic reviews²⁸,²⁹ and a meta-analysis³⁰. Our systematic review expands the literature by being the first to examine attachment typologies, including unresolved/disorganized attachment and dissociation symptoms in their relationship to PTSD symptoms. Unresolved/disorganized attachment was specifically the most associated with PTSD and dissociation symptoms among the other typologies.

Despite this association, unresolved/disorganized attachment is still underappreciated in scientific studies evaluating PTSD and dissociation symptoms. Previous studies²⁸,²⁹,³⁰ show that anxious attachment is more associated with PTSD symptoms. We understand that association between attachment dissociation PTSD the underestimation of unresolved/disorganized attachment in these studies may have influenced this association, since our review found that unresolved/disorganized attachment was more frequently associated with PTSD and dissociation symptoms than anxious attachment. To date, unresolved/disorganized attachment has been studied more in studies with children and adolescents such as the observational study³¹ and meta-analysis³² as well as in narrative reviews³³,³⁴.

The association between PTSD symptoms and dissociation with unresolved/disorganized attachment is understood through the attachment figure's frightening behavior³⁵, which simultaneously maintains the ambiguity between fear and protection. This behavior hinders emotional regulation in disorganized attachment¹³. Therefore, in childhood attachment disorganization, the psychological needs of are not adequately met by caregivers who are often abusive, neglectful, or traumatized. Only in this typology does this contradictory relationship with the attachment figure occur, and consequently, the strategies used in disorganized attachment are freezing or withdrawing in a strange situation³⁶. Thus, the unpredictable emotional reaction of the attachment figure is an early experience of attachment trauma and may contribute to attachment disorganization³⁷ and increased vulnerability to PTSD.

Childhood attachment disorganization predisposes to pathological dissociation³⁸. Freezing states and memory fragmentation are a consequence of the constant feeling of fear of the attachment figure. Defense strategies such as disengagement and barriers to affection emerge in contexts of traumatic loss, real threat, or extreme inconsistency³⁹,⁴⁰. The lack of coherent approach and boundary strategies makes it difficult to learn an organized strategy between approaching and avoiding. These findings are consistent with psychic fragmentation in response to trauma in disorganized attachment⁴¹,⁴². Thus, disorganized attachment is the predictor of a higher risk of dissociation in adults, especially if the environment remains traumatic⁴³,³⁵.

Among the studies that did not assess unresolved/disorganized attachment²⁵, ²⁴,²³, ²⁶, ²⁷ anxious attachment was more frequently associated with PTSD and dissociation. Fear in anxious attachment also promotes states of dissociation, as in disorganized attachment. The difference lies in the structural dissociation⁴¹,⁴³, that generally occurs in disorganized attachment⁴⁴, while dissociation in anxious attachment arises in response to hyperarousal attachment⁴⁵. In anxious attachment, the bond with the caregiver is marked by an intense fear of abandonment, while in disorganized attachment, the relationship is shaped by fear of the caregiver themselves, often due to experiences of abuse. The association between anxious attachment and dissociation is less common compared to disorganized attachment⁴⁶. Probably for this reason, we were unable to find an association between anxious attachment and dissociation in all the studies included in this review²⁵ and although fearful attachment uniquely predicted dissociation, this effect was not mediating on childhood trauma and dissociation²⁶.

Notably, we found in our sample that 44% of women had experienced sexual abuse and 30% had been exposed to other Adverse Childhood Experiences (ACEs). These findings are in line with the previous literature showing that the risk of developing PTSD is significantly higher in cases of interpersonal trauma⁴⁷, and among individuals with insecure attachment patterns⁴⁸, ²⁵,⁴⁹, ⁵⁰.

When compared to men, women are twice as likely to develop PTSD⁵¹,⁵² and dissociation shortly after the trauma⁵³ and insecure attachment and attachment disorganization are also related to abuse⁵⁴,⁵⁵.

The present study has some limitations. First, the differences in attachment assessment strategies, sample characteristics, and analytical approaches limit direct comparability across studies and preclude causal inferences. Some of the studies included in this review used the term insecure attachment and adult attachment without identifying which specific subtypes (e.g., avoidant, ambivalent, disorganized) were linked to PTSD and dissociative symptoms. This lack of detail may have affected the interpretation of the results. While many contemporary classifications of attachment styles broadly align with Ainsworth's original framework¹², differences in how attachment is assessed—ranging from self-report tools to interviews and from categorical to dimensional models—made direct comparisons difficult. This issue has also been raised in earlier research e.g.³⁰,²⁸,⁵⁶ which highlighted how measurement approach can influence outcomes related to PTSD. To address this gap, future studies should explore equivalence across existing assessment methods, including longitudinal designs that follow attachment patterns from childhood into adulthood, as well as analyses that map newer instruments onto the foundational classifications proposed by Ainsworth¹²,¹³. Furthermore, the widespread use of self-report instruments for assessing both attachment and psychopathological symptoms is subject to memory biases, social desirability biases, and limitations in the participants’ mentalization capacity, particularly in populations with a history of trauma.

The second limitation relates to the study designs. The evidence presented here comes primarily from cross-sectional and cohort studies, which restricts our ability to draw conclusions about causality. Also, due a total of nine studies were included, which limits the generalizability of the findings. Although, each included study reported statistically significant associations between specific insecure attachment patterns and PTSD or dissociative symptoms within their respective samples. While the direction of these associations aligns with attachment-based theoretical models of trauma vulnerability, the available evidence does not support causal interpretations or broad generalization. Longitudinal research, particularly involving individuals with unresolved or disorganized attachment styles, is needed to better understand the directionality of these associations.

A third limitation is that our results found an underrepresentation of men who suffered sexual abuse. Men are not generally investigated for this type of trauma. Similarly, we did not find Latin American, African, or Asian ethnicities in the sample of studies included in this review. The predominance of white women in most of the included samples restricts the generalization of the findings to male populations and culturally diverse contexts. Considering that attachment styles—especially disorganized attachment, which is most strongly associated with the investigated outcomes—are shaped by specific sociocultural contexts, the low ethnic and cultural diversity may have influenced the magnitude and direction of the observed associations. Future studies should prioritize more heterogeneous samples, multimethod strategies, and designs that allow for greater precision in assessing these associations.

There are important clinical implications for our findings. This highlights the importance of assessing attachment types, more specifically, the unresolved/disorganized style, in conjunction with dissociative and PTSD symptoms, beyond simply investigating trauma history. The unresolved/disorganized attachment style should also be considered in treatment plans and psychotherapeutic relationships within evidence-based practices, because when disorganized attachment is treated, traumatic memories become more easily integrated and dissociative defenses more difficult to access⁴¹. Currently, attachment theory remains underutilized in treatments for PTSD symptoms⁵⁷,²⁶,⁵⁸ despite evidence that its incorporation can enhance therapeutic outcomes⁵⁹.

5. CONCLUSION

In conclusion, this review suggests consistent associations between insecure attachment, particularly the unresolved/disorganized style, and PTSD and dissociation symptoms. The association between attachment, dissociation and PTSD suggests underscore the relevance of attachment-informed approaches in both the assessment and treatment of PTSD symptoms and support the integration of attachment theory into clinical protocols for individuals with trauma histories.

DATA AVAILABILITY STATEMENT

The data that support this study are available from the authors upon request.

6. ACKNOWLEDGEMENTS

We are deeply grateful to our advisor W.B., whose attentive and generous guidance was fundamental to every stage of this work. We express our sincere gratitude to University for its institutional support. We extend special thanks to all members of the laboratory, who contributed directly and indirectly with dedication, ideas, and daily collaboration. Finally, we thank the reviewers for their valuable suggestions and careful reading, which strengthened the quality of this manuscript.

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Edited by

• Handling Editor:
  Marcia Cristina Dourado

Publication Dates

• Publication in this collection
  24 July 2026
• Date of issue
  2026

History

• Received
  12 Dec 2025
• Accepted
  01 Mar 2026