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Attachment representations in Dutch veterans with and withoutdeployment-related PTSDD. Harari ab; M. J. Bakermans-Kranenburg c; C. S. de Kloet b; E. Geuze de; E. Vermetten de; H. G. M.Westenberg e; M. H. van IJzendoorn c

a Psychotrauma Diagnostic Centre, Centrum45, Utrecht, the Netherlands b Altrecht Mental HealthServices, Utrecht, the Netherlands c Centre for Child and Family Studies, Department of Education andChild Studies, Leiden University, the Netherlands d Military Mental Health - Research Centre, Utrecht,the Netherlands e Department of Psychiatry, University Medical Centre Utrecht, Utrecht, theNetherlands

Online publication date: 16 November 2009

To cite this Article Harari, D., Bakermans-Kranenburg, M. J., de Kloet, C. S., Geuze, E., Vermetten, E., Westenberg, H. G.M. and van IJzendoorn, M. H.(2009) 'Attachment representations in Dutch veterans with and without deployment-related PTSD', Attachment & Human Development, 11: 6, 515 — 536To link to this Article: DOI: 10.1080/14616730903282480URL: http://dx.doi.org/10.1080/14616730903282480

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Attachment representations in Dutch veterans with and without

deployment-related PTSD

D. Hararia,b, M.J. Bakermans-Kranenburgc, C.S. de Kloetb, E. Geuzed,e,E. Vermettend,e, H.G.M. Westenberge and M.H. van IJzendoornc*

aPsychotrauma Diagnostic Centre, Centrum45, Utrecht, the Netherlands; bAltrecht MentalHealth Services, Utrecht, the Netherlands; cCentre for Child and Family Studies, Department ofEducation and Child Studies, Leiden University, the Netherlands; dMilitary Mental Health –Research Centre, Utrecht, the Netherlands; eUniversity Medical Centre Utrecht, Department of

Psychiatry, Utrecht, the Netherlands

(Received 10 November 2008; final version received 5 July 2009)

In this study we tested for a protective effect of secure attachment representationsin the development of posttraumatic stress disorder (PTSD). In a design with acontrol group, we replicated and extended a recent study that found nounderrepresentation of secure attachment representations in veterans with PTSD(Nye, Katzman, Bell, Kilpatrick, Brainard, & Haaland, 2008). Furthermore, weexamined the association of the Adult Attachment Interview (AAI) classificationof unresolved loss or trauma and PTSD symptomatology. The Adult AttachmentInterview and the Clinician Administered PTSD Scale (CAPS) were administeredwith 31 veterans with PTSD and 29 trauma-exposed veterans without PTSD ofsimilar age and country of deployment. Patient and control groups did not differin the prevalence of secure attachment representations, neither did unresolved andnot unresolved subjects differ in prevalence of secure attachment representations.Unresolved state of mind with respect to deployment related trauma was found tocorrelate strongly with total CAPS score. This study shows no protective effect ofsecure attachment representations in the development of PTSD. AAI unresolvedstate of mind with respect to deployment related trauma and PTSD correlatestrongly, due to the common core phenomenon of lack of integration.

Keywords: PTSD; AAI; CAPS; veterans; trauma

Introduction

With the growing use of the Adult Attachment Interview (AAI; Bakermans-Kranenburg & van IJzendoorn, 2009; Hesse, 1999a, 2008; Main & Goldwyn, 1984;Main, Hesse, & Goldwyn, 2008) in various clinical and non-clinical samples, ourunderstanding of the role of attachment representations in the development ofpsychopathology is rapidly increasing (Dozier, Stovall, & Albus, 1999; Harari,Bakermans-Kranenburg, & van IJzendoorn, 2007; Ma, 2006; Steele & Steele, 2008).Yet, at present, only a limited number of studies have applied the AAI to PTSDsamples (Nye et al., 2008; Stovall-McClough & Cloitre, 2006; Turton, Hughes,Fonagy, & Fainman, 2004), focusing on the role of attachment representations in

*Corresponding author. Email: vanijzen@fsw.leidenuniv.nl

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Vol. 11, No. 6, November 2009, 515–536

ISSN 1461-6734 print/ISSN 1469-2988 online

� 2009 Taylor & Francis

DOI: 10.1080/14616730903282480

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specifically trauma related psychopathology. Testing for a possible protective effectof secure attachment representations in the development of PTSD, we applied theAAI to a sample of Dutch veterans. This sample included veterans with and withoutPTSD and was selected in the Central Military Hospital in the Netherlands forstudies of neurobiological alterations in PTSD.

PTSD is listed in the DSM IV under anxiety disorders, as intense fear is an essentialelement of the definition of PTSD, both as part of the experience of the traumatic eventand as part of the clinical presentation (American Psychiatric Association, 1994).PTSD has also been conceptualized as related to dissociative disorders (Bremner,1999; Bremner & Vermetten, 2007; Lanius, Williamson, & Boksman, 2002; Marmar,Weiss, & Schlenger, 1994; Spiegel, Hunt, & Dondershine, 1988). The DSM IVdefinition of PTSD specifies as first criterion the experience of a traumatic eventinvolving an actual or threatened death or serious injury to self or others (DSM IVcriterion A1), which is experienced with intense fear, helplessness, or horror (A2).PTSD symptomatology can be expressed in the domains of intrusive phenomena,avoidance, and hyperarousal.

The DSM IV definition of PTSD does not require explicitly dissociation to bepresent, but in the domains of intrusion and avoidance, forms of dissociation can bephenomenologically recognized. In the experience of intrusive symptoms, the personis absorbed in fearful memories of the event, which may have a vivid sensory andemotional character or even take the form of behavior patterns. The person is thusdissociated from his or her reality in actual time and space. Of the avoidancesymptoms, amnesia has independently been described as a dissociative disorder.Emotional detachment symptoms bear some resemblance to the disorders ofdepersonalization and derealization: while reality-testing is intact, the emotionalinvolvement in the person’s reality in time and space is diminished, possibly in orderto avoid intrusions. Dissociation, imagery and hypnotizability have been shown tobe important components of PTSD symptoms (Spiegel et al., 1988; Vermetten &Spiegel, 2007), providing support for the hypothesis that dissociative phenomena aremobilized as defenses both during and after traumatic experiences.

Dissociation has also been etiologically connected with PTSD. Murray, Ehlers,and Mayou (2002) found persistent dissociation 4 weeks after an accident predictedchronic PTSD severity at 6 months. Briere, Scott, and Weathers (2005) found thattrauma-related persistent dissociation is a predictor of PTSD. Moreover, Fikretogluand colleagues (2006) have linked dissociation to the experience of intense fear,helplessness, or horror at the time of trauma (the A2 criterion of PTSD).

Neurobiological research on PTSD is rapidly expanding (Nemeroff, Bremner,Foa, Mayberg, North, & Stein, 2006). Abnormalities have been found in neuro-endocrinological functioning, particularly of the HPA axis, in neuro-imaging studies,and in genetic studies. The concepts of stress sensitization, fear conditioning, and failureof extinction as underlying psychobiological mechanisms have been empiricallysupported (Bremner, 2003; Charney, Deutsch, Krystal, Southwick, & Davis, 1993).As a next step, studies are undertaken to elucidate the functional role of these concepts.For instance, Gilbertson and colleagues found a diminished hippocampal volume notonly in PTSD patients, but also in their identical twins who had not been exposed totrauma (Gilbertson et al., 2002; Pitman et al., 2006). In a different study, Binder andcolleagues report a gene-environment interaction for PTSD following child abuse,where PTSD is found to develop mostly in subjects with both exposure to child abuseand a specific polymorphism of the stress-related gene FKBP5 (Binder et al., 2008).

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AAI unresolved state of mind and PTSD

A key notion in attachment theory is the concept of internal working models of the selfand the world, which contain information about one’s attachment figures, theiravailability, and theway theyare expected to react in timesofneedanddistress (Bowlby,1973). These models, termed attachment representations, are activated in situations offear and perceived danger and are suggested to affect reactions to fearful andemotionally painful internal and external stimuli. A realistic appraisal of these stimuli,of one’s needs for reassurance andof the potential role of others in alleviating the fear, isguided by secure/autonomous attachment representations. In contrast, the insecure/dismissing representation is characterized by avoiding or suppressing feelings of fearand pain, whereas the insecure/ambivalent representation leads to an angry or passiveresponse, without the ability to rely on support from significant others in coping withfearful stimuli.When a traumatic experience or loss is reflected in the disorganization ofthese reactions, the attachment state of mind is considered unresolved and thisclassification is superimposed on the organized secure or insecure classification.

Unresolved AAI representations are apparent from lapses in the monitoring ofthinking, lapses in the monitoring of discourse related to trauma or loss, ordisorganized behavior following trauma or loss. An example of a lapse of monitoringof thought is a statement like ‘‘My father died 10 years ago’’, followed several pageslater in the text by ‘‘My father wants me to go to law school’’. In this statement twoincompatible beliefs are held, i.e. a belief that the father is dead and a belief that thefather is not dead and still has wishes concerning his child’s choices. An example of alapse of monitoring of discourse would be a sudden change of discourse into lesscoherent speech or into detailed sensory speech. For example, in a coherent andrather factual account of a military mission the subject suddenly says ‘‘a house . . . adoll’s house . . . the front blown off . . . people . . . this smell . . . this smell’’. Here thesubject is absorbed in his memories and is unable to verbalize them coherently. Thesubject appears temporarily not entirely aware of the interview situation. Examplesof reports of dissociated/disorganized behavior occurring in the past include reportsof suicide attempts and of serious aggression regulation problems.

In children, disorganization of attachment (Main & Solomon, 1990) has beendescribed as phenotypically resembling dissociative phenomena (Main & Morgan,1996). Liotti (1992) was the first to suggest that infants’ disorganized/disorientedbehavior in the parent’s presence in the Strange Situation Procedure (Main &Solomon, 1990) bore a phenotypic resemblance to dissociative behavior and couldheighten the likelihood that (if later exposed to traumatic experiences) dissociativedisorders might develop. Main and Morgan further noted the resemblance betweenunresolved slips in the AAI and dissociative phenomena (Main & Morgan, 1996).Liotti’s theory found support in a longitudinal study by Carlson and Ogawa (Carlson,1998; Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997), who showed thatadolescents who as infants displayed disorganized attachment behavior in the StrangeSituation were later strikingly vulnerable to dissociative behavior. In two otherlongitudinal studies, disorganized attachment predicted avoidant PTSD symptomsand intrusion (MacDonald et al., 2008); and unresolved state of mind with respect totrauma predicted dissociation and PTSD (Riggs, Paulson, Tunnell, Sahl, Atkinson, &Ross, 2007). Main and Hesse’s (1990) hypothesis that parental dissociative frightenedor frightening behavior may be the mediating mechanism was tested and confirmedrepeatedly (Madigan, Bakermans-Kranenburg, van IJzendoorn, Moran, Pederson, &

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Benoit, 2006). Main and Hesse theorized that the unpredictable transition of a parentinto a dissociative state places the child in a condition of fright without solution, inwhich attentional and behavioral strategies collapse (Hesse & Main, 2000; Main &Hesse, 1990). In adults with unresolved states of mind, trauma-related lapses incognitive functioning have been linked to absorption in traumatic memories (Hesse &van IJzendoorn, 1999) and to overburdening of the working memory’s capacitybecause attentional processes are drawn towards intensely fearful memories (Hesse &Main, 2006), while fear has a negative effect on working memory (Clark et al., 2003;Moores, Clark, McFarlane, Brown, Puce, & Taylor, 2008; Weber, Clark, McFarlane,Moores, Philip, & Egan, 2005). The concept of lapses in attentional processes in thecase of unresolved attachment converges with findings of reduced neurocognitiveperformance in PTSD (Geuze, Vermetten, de Kloet, Hijman, & Westenberg, 2008;Geuze, Vermetten, de Kloet, & Westenberg, 2008; Hesse & Main, 2006).

Fear and dissociation are closely linked with the etiology and presentation ofboth PTSD and AAI unresolved state of mind. Fearon and Mansell applied acognitive model from PTSD research (Power & Dalgleish, 1997) to AAI unresolvedstate of mind (Fearon, 2004; Fearon & Mansell, 2001). They proposed thatunresolved state of mind represents a lack of integration of trauma/loss relatedrepresentations on different representational levels: analogical (‘‘image-based’’),associative, and propositional. The unresolved subject’s reaction to traumatic cues isdependent on the format of the activated representation and may vary from subtleand limited in time to highly disruptive, which fits well with the phenomenology ofboth unresolved attachment and PTSD.

Attachment security: evidence for protective effects

Security of attachment is defined in the AAI as the capacity to coherently discuss andreflect upon attachment experiences and their consequences for one’s presentfunctioning. Theoretically, secure attachment representations are more efficient thaninsecure representations in adjusting to stressful experiences (Dozier et al., 1999) andmay be a marker of the ability to organize and process stressful experiences indifferent realms of life (Crowell & Hauser, 2008). Psychopathology is associated withattachment insecurity, as in a recent meta-analysis on 105 samples with more than4200 participants secure AAI classifications were clearly underrepresented in clinicalsamples as compared to non-clinical samples (van IJzendoorn & Bakermans-Kranenburg, 2008). A causal role however has not yet been established.

Secure/autonomous AAI attachment status has been suggested to be protectiveagainst the effects of unresolved attachment, which include increased risk ofpsychopathology (Lyons-Ruth & Jacobvitz, 1999) and increased risk of detrimentalbehavior in mother–child interactions (Schuengel, Bakermans-Kranenburg, & vanIJzendoorn, 1999) and in couple interactions (Creasy, 2002). A protective factor inthe development of psychopathology in unresolved subjects was found in a non-clinical sample of adult women by Ward, Lee, and Polan (2006). In their study, amajority of the subjects with insecure AAI classifications suffered some psycho-pathology. Moreover, among the unresolved participants, those with an alternativeinsecure classification were significantly more likely to be diagnosed withpsychopathology than those with an alternative secure-autonomous placement.

Secure/autonomous AAI representations have also been found to be protective inrelation to behavioral sequelae of unresolved trauma and loss. Unresolved mourning

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is associated with subtle frightening behavior in parent–infant interaction and thusforms a risk factor for disorganized infant attachment (Schuengel et al., 1999). Thisrisk for infant attachment disorganization is moderated by security of the parent’sattachment representation. Unresolved but otherwise secure mothers show lessfrightening behavior than unresolved insecure mothers, decreasing the risk for infantattachment disorganization (Jacobvitz, Hazen, & Leon, 2006; Schuengel et al., 1999).Third, a secure maternal attachment representation may also be protective in therelation between postnatal maternal depression and infant insecure attachment.Infants of chronically depressed mothers were more likely to be insecurely attached(McMahon, Barnett, Kowalenko, & Tennant, 2006). However the relation betweenmaternal depression and child attachment was moderated by mothers’ attachment.Mothers with a secure state of mind with respect to attachment, even if chronicallyand severely depressed, were likely to have securely attached children, whereas aninsecure state of mind greatly increased the risk of insecure attachment, irrespectiveof the severity of maternal depression.

Previous studies on AAI status and PTSD

Three studies have applied the AAI in order to examine attachment representations inrelation to PTSD (Nye et al., 2008; Stovall-McClough & Cloitre, 2006; Turton et al.,2004). Stovall-McClough and Cloitre (2006) examined attachment representationsand PTSD symptoms in a sample of adult female childhood abuse survivors, divided ina clinical group with PTSD (n ¼ 30) and a control group without PTSD (n ¼ 30). Inthis study unresolved state of mind related to childhood abuse carried a 7.5-foldincrease in the likelihood of a diagnosis of PTSD related to the abuse. The authorsconcluded that unresolved status contributes most significantly to the diagnosis ofPTSD. Turton and colleagues (2004) examined a community sample of 60 pregnantwomen whose previous pregnancy ended in stillbirth, testing for associations betweenAAI unresolved state of mind with respect to stillbirth, PTSD symptoms related tostillbirth, and infant disorganized attachment at 12 months post partum. In this group,only maternal unresolved status strongly predicted infant disorganization. Nosignificant association was found between AAI unresolved state of mind and PTSD,nor was there an association between maternal PTSD and infant disorganization. Itshould be noted though, that most PTSD symptoms remitted within a year: only 6%of the women had case level PTSD by 12 months post partum. In a sub-sample of 31mothers who were unresolved with respect to stillbirth during their next pregnancy thechildren of 17 mothers were observed to be disorganized at 1-year-old. Remarkably,mothers of these disorganized children showed a significantly lower level ofdepression, and of intrusive thoughts on the PTSD scale completed during pregnancy(Hughes, Turton, McGauley, & Fonagy, 2006). However, these results should beconsidered preliminary because they emerged from a rather large set of analyses onrelated (sub-)scales with non-significant outcomes.

In a third study, attachment organization was examined using the AAI in a groupof 48 Vietnam combat veterans with PTSD (Nye et al., 2008). This study tested threehypotheses. The first hypothesis stated that the prevalence of secure attachmentrepresentations would be lower than in the general population, and that unresolvedattachment would be over represented. The second hypothesis was that subjects withinsecure attachment representations would be more likely to be unresolved, and thethird hypothesis was that lack of resolution would be associated with more axis I

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diagnoses and specifically with severity of avoidance symptoms, but not withintrusions or hyper arousal. Lacking a control group, prevalences of the variousorganized and unresolved attachment classifications were compared with those in thegeneral population (van IJzendoorn & Bakermans-Kranenburg, 1996) and in othernon-clinical populations (Fonagy, Leigh, Steele, Steele, Kennedy, & Mattoon, 1996).Combat experiences were not probed in the AAI, limiting the exploration ofpotentially unresolved states of mind to experiences of loss and of trauma other thancombat. Unresolved state of mind with respect to loss was, as expected,overrepresented in this clinical sample. Surprisingly though, secure/autonomousAAI attachment status was not underrepresented in the clinical sample, but had aprevalence of 50%, which is comparable to the general population with a prevalenceof 62% (van IJzendoorn & Bakermans-Kranenburg, 1996). An update, which wasnot available at the time of this study, yielded a prevalence of secure/autonomousAAI attachment status in non-clinical groups of 56%, which is even closer to theprevalence found by Nye and colleagues (van IJzendoorn & Bakermans-Kranen-burg, 2008). Nye et al. (2008) found more unresolved loss among insecure subjectsthan among secure subjects, and unresolved loss was associated with more co-morbid anxiety disorders and with PTSD avoidance/numbing symptoms.

Taken together, the overrepresentation of unresolved state of mind with respect toloss, and the absence of an underrepresentation of secure attachment representationsin this clinical PTSD sample, suggest a possible role for unresolved loss as risk factorfor PTSD and no role for secure state of mind as a protective factor in the developmentof PTSD. However, as Nye and colleagues stated, the cross-sectional design of thestudy and the lack of control group precluded conclusions about causal relationsbetween the various variables. Moreover, there was a very high rate of psychiatric co-morbidity in the sample, where all participants had at least one lifetime co-morbiddiagnosis with a median number of additional axis I diagnoses of three. We aim atreplicating the study of Nye et al. in a well-defined PTSD sample with less co-morbidity and a trauma control group without PTSD.

Various forms of unresolved state of mind

In the three studies described above, different forms of AAI unresolved state of mindwere assessed. Stovall-McClough and Cloitre (2006) measured unresolved traumarelated to childhood abuse for which PTSD symptoms existed. Turton et al. (2004)report in their study on unresolved state of mind and PTSD following stillbirth onlythe unresolved state of mind related to the stillbirth. In another study on unresolvedstate of mind after stillbirth, this research group reports on unresolved state of mindin relation to childhood trauma as well. Here, in a case controlled design, womenafter stillbirth were more likely to be unresolved in relation to childhood traumathan control women, although prevalence of childhood trauma was equal in bothgroups (Hughes, Turton, Hopper, McGauley, & Fonagy, 2004). Nye and colleagues(2008) assessed unresolved state of mind regarding experiences of loss and of traumaother than the traumatic combat experiences which were associated with PTSD. Theauthors considered the group of unresolved subjects to primarily give evidence ofunresolved loss. Unresolved combat trauma was not assessed.

We decided to assess both unresolved state of mind with regard to deploymentrelated trauma and unresolved state of mind with regard to trauma and loss notrelated to deployment. As stated earlier, when a trauma is associated with PTSD

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symptoms and is assessed as unresolved in the AAI, we consider the AAI unresolvedclassification to reflect a lack of integration present in PTSD as well. Moreover,whether or not PTSD symptoms exist, AAI unresolved status could be considered apossible risk factor for PTSD following later traumatic experiences. Distinguishingbetween deployment related trauma and not deployment related trauma allowed usto speculate about the possible role of non-deployment unresolved loss and traumaas risk factors for later PTSD. However, for definite conclusions regarding lack ofresolution as a risk factor for PTSD, a longitudinal design is needed.

Previous research on the current sample

Several studies on neurobiological determinants and correlates of PTSD in this samplehave been reported. Alterations in HPA-axis functioning and AVP level were relatedto either trauma exposure or to PTSD. Enhanced cortisol suppression in response todexamethasone was found in the clinical as well as in the non-clinical group, and thusfound to be related to trauma exposure and not to PTSD specifically(de Kloet,Vermetten, Geuze, Lentjes, et al., 2007). Plasma corticotrope releasing hormone levelsand plasma vasopressin levels were found to be higher in the clinical PTSD group andto be specifically related to PTSD and not to trauma exposure (de Kloet, Vermetten,Geuze, Lentjes, et al., 2007; de Kloet, Vermetten, Geuze, Wiegant, & Westenberg,2007). The combined DEX-CRH test revealed no differences between the clinicalgroup and the control group, but in a subgroup of PTSD patients with co-morbiddepression a blunted adrenocorticotrope hormone response was found (de Kloet et al.,2008). The additional assessment of attachment representations in this sample enablesus to extend the neurobiological approach with a developmental perspective, and totest for possible protective factors and correlates of trauma related pathology.

Hypotheses

I. Secure/autonomous AAI attachment status, as a protective factor in thedevelopment of PTSD, will be underrepresented in the clinical group, ascompared to the control group, and will be underrepresented in unresolvedsubjects as compared to not unresolved subjects.

II. Since both PTSD and unresolved attachment state of mind are characterized bylack of integration, unresolved deployment related trauma (Utrauma deployment)will be overrepresented in the PTSD group as compared with the traumacontrol group and will distinguish between PTSD patients and controls.Severity of Utrauma deployment will correlate with severity of PTSD.

III. Unresolved state of mind with respect to non-deployment loss or non-deployment trauma Unon-deployment loss/trauma will be overrepresented in theclinical group and will be associated with more co-morbidity and more severesymptoms of numbing and avoidance.

Method

Design

The current study was part of a larger investigation into the neurobiology of PTSD,for which data-collection took place in the Central Military Hospital in Utrecht, theNetherlands, in the years 2002–2005. The study is a cross-sectional descriptive study

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investigating what differentiates PTSD patients from traumatized controls. Thestudy was approved by the Institutional Review Board of the University MedicalCenter Utrecht. Written informed consent was obtained from all subjects whoparticipated in the study after receiving a complete written and verbal description ofthe study.

Sample

PTSD patients were recruited from the Department of Psychiatry of the CentralMilitary Hospital in Utrecht, the Netherlands. Twenty six veterans, who werediagnosed with PTSD in the period of August 2002 to August 2005, were recruited,as well as seven veterans who were already in treatment for PTSD. Controls wereselected from a group of veterans registered at the Dutch Veteran Institute. Theclinical group and the comparison group had similar distributions of age, year ofdeployment, and country of deployment (see Table 1). In both groups,approximately half the subjects had been deployed to Bosnia. The rest had beendeployed to Lebanon, Cambodia, Afghanistan, and Kosovo, with distributionscomparable in both groups. Subjects who had a history of neurological illness or asignificant medical illness were excluded.

Measures

Structured Clinical Interview for DSM IV axis I disorders (SCID-I)

All veterans were screened for psychiatric illness using the Structured ClinicalInterview for DSM IV axis I disorders (SCID-I).

Clinician Administered PTSD Scale (CAPS)

The diagnosis of PTSD was confirmed by the Clinician Administered PTSD (Blake,Weathers, Nagy, Kaloupek, Klauminser, & Charney, 1998) and after consensus bythree clinicians (CdK, EV, EG). The CAPS is a structured diagnostic interviewwhich yields both a diagnosis and a measure of symptom severity. It has high inter-rater reliability (Blanchard, Jones-Alexander, & Buckley, 1996; Hovens, Ploeg, &Klaarenbeek, 1994). In order to be included in the patient group, subjects had tohave a score of 50 or more on the CAPS and had to meet DSM IV criteria for PTSD.Subjects with a current comorbid DSM IV axis I disorder other than mooddisorders, anxiety disorders (including somatoform disorder), or substancedependence were excluded from the patient group. Subjects were included in the

Table 1. Demographic variables for patients and controls.

Patient(n ¼ 31)

Control(n ¼ 29)

M SD M SD t p

Deployment age 23.10 4.08 21.76 2.50 1.52 .13Assessment age 33.90 5.08 35.41 5.19 71.14 .26Frequency deployment trauma 3.97 1.83 3.83 1.54 0.32 .75

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control group if they met A1 criteria for PTSD, had a CAPS score below 25, and ifthey did not meet lifetime DSM IV criteria for PTSD or DSM IV criteria for anycurrent axis I disorder, as measured by the SCID.

Early Trauma Inventory

Life time trauma was scored with the Early Trauma Inventory. Traumatic eventsduring deployment were scored in the part of the CAPS related to the A1 criterion.

Co-morbidity

Lifetime co-morbidity

In the clinical group the following prevalences for lifetime diagnoses were found:somatoform disorder 6.5%, panic disorder 9.7%, bipolar disorder 3.2%, alcoholabuse 3.2%, and substance abuse 9.7%. In the control group, one subject (3.4%) hada history of panic disorder and four subjects (13.8%) had a lifetime diagnosis of amajor depressive episode.

Current co-morbidity

Presence of a current DSM Axis I diagnosis was an exclusion criterion for thecontrol group. In the clinical group, 29.0% of subjects had no current co-morbidity.A current major depressive episode was diagnosed in 45.2% of the subjects in theclinical group. Cannabis dependence was diagnosed in 13.8%, alcohol dependence in6.4%, and panic disorder in 9.6%. The following diagnoses were each present in oneor two subjects: somatoform disorder (6.4%), social phobia (6.4%), pain disorder(6.4%), OCD (3.2%), hypochondria (3.2%), bipolar II disorder (3.2%), andagoraphobia without panic disorder (3.2%).

The Adult Attachment Interview (AAI)

This semi-structured interview confronts the subject with the dual task ofmaintaining a coherent and collaborative discourse, while concentrating onattachment related memories (Main, Goldwyn, & Hesse, 2003). Subjects are askedto give an evaluation of their relations with their parents in childhood and to providespecific examples supporting this evaluation. Memories of illness, separation, andfearful experiences in childhood are probed, as well as all traumatic experiences andexperiences of loss. Security of attachment in the AAI is defined as a correlate ofcoherence of the subjects’ discourse and thought regarding attachment related issuesof the past and the present. A high to moderate coherence is indicative of secureattachment representations. Idealization, denial, and lack of memory are examplesof incoherency related with insecure/dismissing attachment representations. Vagueand passive speech and speech indicative of preoccupation through anger or fear areincoherencies related to the insecure/ambivalent representations. Although the AAIprobes for all potentially traumatic experiences, we added an explicit questionprobing for deployment related trauma.

The AAI has been thoroughly tested for reliability and predictive anddiscriminant validity. A 90% test-retest reliability was found by Sagi et al. (1994)

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(k ¼ .79; n ¼ 59) over a 4-month period. Bakermans-Kranenburg and vanIJzendoorn (1993) found 78% reliability (k ¼ .63; n ¼ 83) across the three organizedattachment categories over a 2-month period. Benoit and Parker (1994) found 90%stability for the three-category classifications (k ¼ .79; n ¼ 84) and 77% for thefour-category classifications (k ¼ .63; n ¼ 84) over a year. In a 1995 meta-analysison 18 studies (van IJzendoorn, 1995), a large effect size was found for the relationbetween security in the AAI and security of observed parent–child relation in theStrange Situation Procedure. Also, the unresolved adult category U predicted thedisorganized infant category significantly. AAI Unresolved state of mind (U) isscored along a continuous scale from 1–9. The cut off score for presence ofdisorganization is 5. Thus unresolved state of mind can be analyzed both as adichotomous variable (presence or absence of unresolved attachment) and as acontinuous one (severity of unresolved attachment).

The AAI was administered to the subjects by DH, and the interviews were codedby DH, who has been trained by D. Jacobvitz and by S. Golman de Milan and J.Sroufe and certified in the AAI classification system. Earlier research hasdemonstrated that interviewing the subjects does not interfere with coding thesame subjects’ interviews (Sagi et al., 1994). Seventeen cases were also coded by MB.Inter-rater agreement in this sample was 83% for the three-way classification and forthe U–non U classification. Kappa for coding security versus insecurity was .60(n ¼ 17, p 5 .05) and for Unresolved state of mind versus no Unresolved state ofmind was .63 (n ¼ 17, p 5 .05). Cases where classification was not clear were doublecoded and/or discussed to consensus. Where not explicitly stated otherwise, the four-way classification was used in the analyses. One subject who was CC (CannotClassify) (Hesse, 1999b), as well as Unresolved, was included in the Unresolvedgroup.

AAI classification of traumatic experiences

Traumatic experiences during deployment were termed deployment related trauma.Examples of deployment related trauma are the experience of combat situations inwhich the subject was shot at, the experience of having been taken hostage,witnessing severe human suffering such as hungry children or severely woundedcivilians, and the death of colleagues. AAI Unresolved states of mind scores relatedto these trauma were termed Udeployment trauma.

All loss and trauma that occurred before or after deployment were groupedtogether as non-deployment loss or trauma, and AAI unresolved state of mind withregard to these were termed Unon-deployment loss/trauma. Examples of non-deploymenttrauma were child abuse, the experience of having one’s pets unexpectedly andviolently killed in childhood, car accidents, and being a victim of violent crime. Nosexual abuse was reported in this sample. Examples of non-deployment loss are thedeath of one’s parents, siblings, or other close ones.

Analysis

Two tailed independent sample t-tests were performed on the main variables for thepatients versus controls, for the unresolved subjects versus the not unresolvedsubjects, and for subjects with secure/autonomous state of mind versus subjects withinsecure state of mind. When testing subjects with secure versus insecure states of

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mind we used the so-called forced three-way classification. In the forced three-wayclassification unresolved state of mind is not taken into account, implying thatsubjects with a secure and at the same time unresolved state of mind are consideredsecure, just like subjects who were classified as secure/autonomous without theadditional classification as unresolved. Oneway ANOVAs were performed on themain variables for the classifications secure/autonomous (F), insecure (nonF),Unresolved/secure (U/F) and Unresolved/insecure (U/nonF). Pearson’s correlationswere computed for the associations among the main variables. A chi-square test wasperformed for the prevalence of Unon-deployment loss/trauma in the patient versus controlgroup.

Results

Security of attachment

Prevalence of secure/autonomous AAI attachment status in the three way analysiswas equal in the clinical group (48.4%) and in the control group (48.2%). Among thesubjects with insecure AAI attachment status in both the clinical and the controlgroups we found highly similar distributions of the insecure/dismissing category Ds(35.5% for patients and 34.5% for controls) and the insecure/ambivalent category E(16.2% for patients and 17.2% for controls). Secure/autonomous AAI attachmentstatus was not underrepresented in unresolved subjects (48.3%) versus notunresolved subjects (51.7%). When subjects were divided into secure/autonomousAAI attachment status and insecure attachment status, there were no significantdifferences on any of the main variables (Table 2). Security of attachment was notassociated with total PTSD symptoms, with unresolved state of mind related todeployment trauma or to other unresolved trauma or loss, nor with presence oflifetime depression.

Unresolved deployment related trauma

Unresolved trauma related to deployment (Udeployment trauma) was overrepresented inthe clinical group (87.1%) compared to the control group (6.9%). Patient andcontrol groups significantly differed in continuous scores for unresolved deploy-ment trauma, t(58) ¼ 12.18, p 5 .01 (two-tailed) (Table 3). Severity of unresolveddeployment trauma showed a strong correlation with severity of total PTSDsymptomatology as expressed in CAPS-score (r ¼ .80, p 5 .001; n ¼ 60) (Table 4).

Unresolved non-deployment related loss and trauma

The classification of Unresolved non-deployment loss or trauma (Unon-deployment loss/

trauma) was overrepresented in the clinical group (42%) as compared to the controlgroup (7%), w2(1, N ¼ 60) ¼ 9.81, p ¼ .02. A t-test on the continuous scores forUnon-deployment loss/trauma yielded no significant differences for the continuous scoresof the patient group and control group. Of the two controls who were unresolved forloss or non-deployment trauma, one was unresolved for a loss that took place beforehis deployment and one was unresolved for a loss that took place after hisdeployment. Of the 13 patients who were unresolved for loss or non-deploymenttrauma, six were unresolved for losses that occurred after their deployment and onewas unresolved both for pre-deployment loss and for post-deployment loss. Leaving

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Table

2.

Meansandstandard

deviationsforunresolved

andnotunresolved

secure

andinsecure

attachmentclassifications.

F(n¼

15)

NotF

(n¼

16)

U/F

(n¼

14)

U/N

otF

(n¼

15)

U/F

versusU/N

otF

MSD

MSD

MSD

MSD

Fp

T

Deploymentage

21.33

2.66

22.50

2.68

23.50

4.72

22.53

3.48

0.96

.42

70.75

Assessm

entage

34.13

5.78

35.50

4.34

34.36

5.32

34.47

5.53

0.21

.89

0.06

Traumaexperienced

4.27

1.67

3.19

1.56

3.93

1.94

4.27

1.49

1.46

.23

0.55

CAPS

17.20

23.38

14.88

23.50

66.64

29.85

66.27

21.98

20.79

5.01

70.04

Udeploymenttrauma

2.10

1.45

2.06

1.82

5.79

1.35

5.97

1.06

34.06

5.01

0.34

Unon-deploymentloss/trauma

2.20

1.45

2.41

1.52

4.25

2.85

3.33

2.39

3.03

.04

71.20

Depressionlifetime1

0.29

0.47

0.13

0.34

0.75

0.45

0.71

0.47

7.36

5.01

70.21

Depressioncurrent

0.20

0.56

0.19

0.54

1.38

0.77

1.20

0.56

16.05

5.01

70.80

1n¼

4missing.

526 D. Harari et al.

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Table

3.

Meansandstandard

deviationsofthemain

variablesforpatients

andcontrols,andattachmentclassificationgroups.

Patient

(n¼

31)

Control

(n¼

29)

U(n¼

29)

NotU

(n¼

31)

F(n¼

29)

NotF

(n¼

31)

MSD

MSD

tp

MSD

MSD

tp

MSD

MSD

tp

Deploymentage

23.10

4.08

21.76

2.50

1.52

.13

23.00

4.08

21.93

2.69

1.20

.24

22.38

3.89

22.52

3.04

70.15

.88

Assessm

entage

33.90

5.08

35.41

5.19

71.14

.26

34.41

5.33

34.84

5.05

70.32

.75

34.24

5.46

35.00

4.89

70.57

.57

Traumaexperienced

3.97

1.83

3.83

1.54

0.32

.75

4.10

1.70

3.71

1.68

0.90

.37

4.10

1.78

3.71

1.60

0.90

.37

CAPS

70.87

19.68

7.79

6.61

16.861

5.01

66.45

25.60

16.00

23.08

8.03

5.01

41.07

36.32

39.74

34.40

0.15

.89

Udeploymenttrauma

5.86

1.28

1.85

1.27

12.18

5.01

5.88

1.19

2.08

1.62

10.381

5.01

3.88

2.33

3.95

2.47

70.12

.91

Unon-deploymentloss/trauma

3.44

2.45

2.53

1.76

1.58

.12

3.78

2.62

2.30

1.33

2.711

.01

3.19

2.35

2.86

2.01

0.59

.56

Depressionlifetime2

0.75

0.44

0.14

0.36

5.671

5.01

0.73

0.45

0.20

0.41

4.62

5.01

0.50

0.51

0.40

0.50

0.74

.46

Depressioncurrent

1.40

0.56

0.00

0.00

13.611

5.01

1.29

0.66

0.19

0.54

6.911

5.01

0.75

0.89

0.68

0.75

0.34

.73

1unequalvariances.

2n¼

4missing.

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Table

4.

Pearson’scorrelationsamongthemain

variables.

Deployment

age

Assessm

ent

age

Trauma

experienced

CAPS

Udeployment

trauma

Unon-deployment

loss/trauma

Depression

lifetime

Deploymentage

Assessm

entage

.14

Traumaexperienced

7.07

7.02

CAPS

.09

7.10

.05

Udeploymenttrauma

.13

7.10

.07

.80**

Unon-deploymentloss/trauma

.10

7.04

.08

.21

.32*

Depressionlifetime1

.12

7.10

.20

.54**

.49**

.12

Depressioncurrent

.20

7.07

.03

.91**

.70**

.27*

.57**

1n¼

4missing.

*significantatthe.05level

(2-tailed).

**significantatthe.01level

(2-tailed).

528 D. Harari et al.

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out the post-deployment losses, a significant overrepresentation of the classificationUnon-deployment loss/trauma remained in the clinical sample (22.6%) compared to thecontrol sample (3.4%), w2(3, N ¼ 60) ¼ 9.89, p ¼ .02. In the total sample theprevalence of Unon-deployment loss/trauma in the group of secure subjects (27.6%) did notsignificantly differ from prevalence in the group of insecure subjects (22.6%).

Similar to the Nye et al. (2008) study, Unon-deployment loss/trauma largely equaledunresolved state of mind with respect to loss. Only one subject was unresolved fortraumatic childhood experiences, while not having any unresolved loss. There wereno unresolved loss experiences related to deployment. Unon-deployment loss/trauma

showed no significant correlation with total CAPS-score or with score on the C-criterion of numbing/avoidance. In the clinical group, Unon-deployment loss/trauma

showed no significant correlation with current depression. For the control group,current depression was an exclusion criterion.

Discussion

In the current study we compared Dutch veterans who were diagnosed withdeployment-related PTSD with trauma control veterans who were exposed todeployment related traumatic events without PTSD, but of similar age and year andcountry of deployment and trauma exposure. In support of our hypothesis we foundthat unresolved state of mind with respect to deployment-related traumadifferentiated between the two groups and correlated strongly with severity ofPTSD symptoms. The AAI classification Unresolved with respect to non-deployment loss/trauma was significantly overrepresented in the patient groupcompared with the control group, although the continuous score for unresolved stateof mind did not differentiate between the two groups. The two groups were similar inprevalence of attachment security and in distribution of (forced) three-wayattachment classifications in general.

Attachment security

We were not able to support our hypothesis of underrepresentation of secure/autonomous AAI attachment status in the clinical group, as prevalence of thisclassification was equal in both groups (48.4% and 48.2%). This finding is areplication of the finding of Nye and colleagues (2008), who found a prevalence ofsecure/autonomous attachment status (50%) in their clinical PTSD samplecomparable to the prevalence in the general population (62%) according to a recentmeta-analysis (van IJzendoorn & Bakermans-Kranenburg, 2008). We also could notsupport our hypothesis of underrepresentation of secure/autonomous AAI attach-ment status in the group of unresolved subjects, as prevalence of this classificationwas equal in the group of unresolved (48.3%) and the group of not unresolvedsubjects (51.7%). This finding is in contrast with Nye and colleagues’ findings, wheresubjects in the insecure group were more likely to be classified as unresolved for lossthan subjects in the secure group.

Thus, no evidence was found for a protective effect of secure/autonomous AAIattachment status in the development of PTSD or in the development of unresolvedtrauma. The use of a control group similar to the clinical group in age, deploymentcharacteristics and traumatic experiences, and the finding of similar prevalences ofthe forced, three-way attachment categories in both groups supports the conclusion

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that attachment security is not a protective factor in PTSD. However, since ourdesign is not longitudinal, the question arises whether one can assume that theseprevalences remained unchanged since prior to and during deployment.

Several studies provide evidence for the long-term stability of adult secure stateof mind as assessed through the AAI. Benoit and Parker (1994) found stability ofsecure/autonomous AAI attachment status over a year, with child birth in-between.Crowell, Treboux, and Waters (2002) also found impressive stability of secure stateof mind over a 21-month period. Two studies tested stability of attachmentclassification over even longer periods of several years. Ammaniti, Speranza, andCandelori (1996) found stability across a 4-year period and Steele and Steele (2007;cited by E. Hesse) reported stability over a period of 5 years. The studies listed aboveused low risk samples and reported a higher stability of secure/autonomous AAIattachment classification as compared with insecure attachment classifications. In ahigh risk sample, insecure attachment classifications have been found to be highlystable. Crowell and Hauser (2008) studied a sample of hospitalized adolescents, whowere followed up to age 39 and found stability of the secure versus insecureclassification over a 13-year period from age 26 to 39. In this sample, prevalence ofsecure/autonomous AAI attachment classification was low and, in contrast with lowrisk samples, stability of the insecure classifications was high compared with thesecure classification.

Thus, stability of secure/autonomous AAI attachment status has been extensivelydocumented in low-risk and, to a lesser extent, high-risk samples. We consider ourcomparison group a low risk sample as military personnel had to be functional inorder to be selected for deployment. In contrast, our clinical group consists ofsubjects who were functioning well until deployment but, at the time of the study,this group was by definition a clinical, that is high risk, sample. However, thedocumented stability of insecure AAI attachment status in high-risk subjects cannotexplain the equal prevalence of secure/autonomous AAI attachment status in bothgroups, if secure attachment were protective in development of PTSD.

The finding that securely attached persons are just as likely to develop PTSD asinsecurely attached persons, and that PTSD patients are not less secure orautonomous than the general population, may come as a confirmation of clinicalexperiences for many trauma therapists. This finding provides an encouragingperspective on the treatment of PTSD, given the importance of attachmentrepresentations to psychotherapy (Steele & Steele, 2008). As Dozier and Batesargue, the treatment relationship is often an attachment relationship, as it isinherently interpersonal and involves caregiving and is thus shaped by both thetherapist’s and the client’s attachment states of mind (Dozier & Bates, 2004). Bowlbyconceptualized the role of the therapist as a reliable attachment figure who providesa temporary secure base from which patients can explore and solve their problems(Bowlby, 1988). A patient with a secure attachment state of mind can be expected tobe better capable of using this secure base in therapy.

Unresolved state of mind with respect to loss or trauma

As expected, unresolved state of mind with respect to deployment-related traumawas overrepresented in the clinical group, distinguished between patients andcontrols and correlated significantly with severity of PTSD symptoms. Theconvergence between AAI unresolved state of mind and PTSD symptomatology is

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remarkable as AAI unresolved state of mind and PTSD differ in severity ofpresentation, in prevalence in general populations and in the theoretical perspectivefrom which they were constructed. These findings support the view that AAIunresolved state of mind and PTSD symptomatology share lack of integration as acommon core phenomenon. This core phenomenon consists of the occurrence ofdiscrete trauma-related disruptions of thought, speech, and action. The disruption ofpsychological functions through intrusion of traumatic experiences is conceptualizedin Fearon and Mansell’s model of unintegrated memory systems (Fearon, 2004;Fearon & Mansell, 2001). The statement that AAI unresolved trauma and PTSDshare a common core phenomenon should not be misinterpreted as equating these.There may be an asymmetric relation in the sense that not all AAI unresolvedtrauma involves PTSD, while PTSD would almost always involve AAI unresolvedtrauma.

Concerning unresolved state of mind with respect to non-deployment loss ortrauma we found that as expected, and as found by Nye et al. (2008), this unresolvedstate of mind was overrepresented in the clinical group. There was however noassociation with co-morbidity, nor with total PTSD severity nor with severity ofnumbing and avoidance. From the overrepresentation of unresolved state of mindwith regard to non-deployment loss and trauma no conclusions can be drawn, as longas one cannot assume that the unresolved state of mind for these losses and traumashas been stable and was present before PTSD developed. Several studies found theAAI unresolved classification less stable in time than the secure/autonomousclassification. In the study by Bakermans-Kranenburg and van IJzendoorn (1993),taking unresolved classification into account reduced stability of classification. In thestudy by Benoit and Parker (1994), stability rested primarily in the autonomousclassification while the majority of changes in attachment classification involved theunresolved classification. Crowell, Treboux, and Waters (2002) found evidence ofstability for unresolved state of mind with regard to loss but not for unresolved stateof mind with regard to trauma. In a high risk sample of subjects hospitalized inadolescence, Crowell and Hauser (2008) found the unresolved classification not stableover 13 years. Levy and colleagues (2006) however found in subjects diagnosed withborderline personality disorder a high stability for the unresolved classification over ayear of intensive psychotherapy. In light of this equivocal evidence, conclusions aboutpre-existent unresolved loss as a risk factor for PTSD have to remain speculative aswe assessed all unresolved loss and trauma in our study at one moment in time.Nevertheless, it seems a fruitful hypothesis for future longitudinal studies on theeffects of traumatizing deployment to take into account the predeploymentattachment state of mind of the subjects. A recent study by Koenen et al. whichfound that negative childhood experiences predicted PTSD in adulthood supportsthis approach (Koenen, Moffit, Poulton, Martin, & Caspi, 2007).

In conclusion, similar numbers of secure AAI attachment representations in aPTSD sample compared with a control group, combined with evidence that securityof attachment is highly stable over time, support the conclusion that security ofattachment is not a protective factor in development of PTSD. Overrepresentation ofunresolved state of mind with respect to deployment related trauma, and a strongcorrelation of this unresolved category with presence and severity of PTSD issuggested to be a reflection of a common core phenomenon of dissociated thoughts,feelings, and actions. Finally, the current findings are compatible with a possibleetiologic role of unresolved loss or unresolved pre-existent trauma in the

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development of PTSD. We recommend that future research on development ofPTSD will focus on unresolved loss or unresolved pre-existent trauma, rather thanon security of attachment.

Acknowledgements

MJBK and MHvIJ were supported by research awards from the Netherlands Organization forScientific Research (MJBK: VIDI grant no. 452-04-306; MHvIJ: NWO SPINOZA prize). Thestudy was facilitated by financial support from the Dutch Department of Defence.

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