Throughout history there have been psychological effects on
Soldiers and their Families during combat deployment. (1) Posttraumatic
stress disorder (PTSD) is an anxiety disorder that may occur following
an emotionally terrifying, life-threatening event or events that create
psychological trauma. Events associated with onset of PTSD include, but
are not limited to:

It is estimated that 5% to 24% incidence of PTSD for the over 2
million American troops deployed to Iraq and Afghanistan occurred from
September 2001 until October 2009. (3) Primary characteristics of PTSD
are debilitating fear and helplessness. (4) As such, severe PTSD
symptoms can be detrimental to the overall life and functioning of the
individual, with consequences at the biological, psychological, and
social levels. The social implications of PTSD directly relate to
attachment theory and the disruption of ways we relate with others in
our social support system. (5) Attachment theory provides a framework
for understanding and addressing the central problems of PTSD that
affect psychosocial functioning: emotion or affect regulation,
interpersonal skills, and social support behaviors. (6,7)

ATTACHMENT THEORY AND ATTACHMENT PATTERNS/STYLES

Adult attachment is an extension of the early attachment
relationship between the infant and caregiver. (8) This relationship
sets the foundation for all future attachment relationships and the
"internal working model" of self and of others. The theory
concentrates on secure attachments between infants and their caregivers
as related to the development of social and emotional stability.
Moreover, the ideal of secure attachment "assumes that successful
navigation through the universal stages of attachment normatively
provides children with a secure emotional attachment base, a base from
which children competently lead the rest of their relational
lives." (9)

Child attachment theory was developed in the 1970s by Mary
Ainsworth, (10) who established 3 different attachment styles in
children: type B or secure, type A or avoidant, and type C or
ambivalent/resistant. A fourth category identified by Main and Solomon
(11) was labeled as disoriented or disorganized attachment, or type A/C.
(8) The field was further developed by Bowlby (8) who asserted the first
attachment relationship between the infant and caregiver (usually the
mother) sets the stage for all future attachment relationships. In their
studies of romantic love, Hazan and Shaver (13) developed a 3-category
theory of adult attachment based on Ainsworth's original 3
infant-parent styles. Their styles were labeled secure, avoidant, and
ambivalent. As with the child literature, a fourth adult attachment
category was added by Bartholomew. (13) Bartholomew's styles are
secure, preoccupied, fearful, and dismissing. Conceptually, the secure
and preoccupied styles are similar to Hazan and Shaver's (12)
secure and ambivalent styles, whereas fearful and dismissing describes 2
different types of avoidant individuals. More recently, the adult
attachment literature has expanded to look at adult attachment more
succinctly as a composite of relationship anxiety and relationship
avoidance.

Attachment style is based on how you feel about yourself and about
others. In Bartholomew's styles, secure describes low relationship
anxiety and low avoidance, preoccupied indicates high anxiety and low
avoidance, fearful depicts high anxiety and high avoidance, and
dismissing characterizes low anxiety and high avoidance. Additionally,
insecure adults may have anxious-resistant attachment, which means they
worry that their partner may not love them completely, and they are
emotionally reactive when their attachment needs go unmet. Conversely,
avoidant partners appear not to care too much about close relationships;
they are not dependent on others and others cannot be dependent on them.
(12) The attachment research literature shows that individuals with
secure attachment "score higher on personality variables indicative
of self-confidence, psychological well-being, and functioning in the
social world." (15) Securely attached individuals are also
described as "adaptive, capable, trusting and understanding,"
as well as "able to appraise stressful situations, cope more
positively with them, and adjust more flexibly to these
experiences." (14)

POSTTRAUMATIC STRESS DISORDER AND SOCIAL BONDS

Interpersonal factors play a large role in the diagnosis,
development, maintenance, and recovery from PTSD. From a diagnostic
perspective, symptoms of social impairment include various degrees of
withdrawal from relationships and social roles. In terms of development,
PTSD diagnoses often result from interpersonal trauma, such as rape and
abuse, as compared with natural disasters, or even the trauma of combat
itself. As such, it appears that PTSD involves a dissembling of the
internal structures of trust and attachment that allow us to connect
with important others and to function normally in social settings as a
result of this breach in social bonds via trauma. Regardless of the kind
of traumatic experience, people with PTSD suffer extreme social
difficulty due to the impairment to the ability to distinguish between
dangerous and normal stimuli. (16) Trauma studies show that the
biophysical, psychological, and social functioning of individuals with
PTSD is comprised at neurophysiological levels in such a way that limbic
systems for self regulating or self-calming are disrupted; rational
thinking and action are debilitated; and interpersonal relationships as
well as social bonds are often broken. It is important to note that
social support processes are at play within these sequelae of PTSD and
the severity of symptoms. (17) People with PTSD have difficulty drawing
on social support when they need it most. (18) And in turn, resources of
social support tend to diminish as people with PTSD are unable to reach
out for help. (19) Several studies show that social support is an
important factor in adjustment and functioning for Veterans with PTSD.
(20,21) While severity and prognosis are varied, the impact on military
performance, family, and quality of life has precipitated significant
clinical and research interest.

Closely related to social support, particularly through the lens of
attachment theory, is the experience of intimate partner relationships.
Importantly, intimate partner relationships are also known to be an
important factor in overall functioning for Veterans and Soldiers, if
not for all families. (22) This area of research provides a particularly
informative application of attachment theory in light of attachment
styles with adult romantic partners, which is considered by current
attachment theory to be an extension of the individual attachment style
established with the primary caregiver. (23) Recent research shows that
this theory is supported in its application to dyadic, or couple's
processes in PTSD outcomes. (24-27) This growing body of research shows
that PTSD is associated with insecure attachment styles. (27,28)
Additionally, recent studies have shown that marital functioning and
couple adjustment is an important aspect for Veterans and Soldiers with
PTSD. (24,29) Two recent studies show that marital satisfaction plays an
important role in lower symptom severity of Veterans with PTSD. (30,31)
This theoretical perspective is beginning to provide insight into the
interpersonal factors at work in PTSD outcomes, making this an opportune
time to further explore relationships between mechanisms of attachment
and PTSD in recent Veterans. (24-26) Posttraumatic stress disorder has
recently been increasingly associated with attachment theory due to the
interpersonal nature of the disorder. (32)

THE CURRENT STUDY

Data from a cross-sectional study were analyzed to further explore
the relationship between attachment styles and PTSD. Of note, this study
examined the relationship between PTSD symptoms and 2 different but
theoretically and empirically related assessments of human attachment.
Regarding the first assessment, our first hypothesis was that PTSD
symptoms would be differentially related to each of the categorical
attachment measure styles. We expected the higher PTSD scores to be
associated with the fearful group and the lower PTSD scores to be
associated with the secure group.

It is also hypothesized that relationship anxiety and relationship
avoidance would predict reported PTSD scores with low relationship
anxiety and low relationship avoidance being related to lower PTSD
scores with the opposite being related to higher PTSD scores.

METHODS

Procedure

Data were collected as part of a quantitative, cross-sectional
study looking at attachment, temperament, and resilience as protective
mechanisms for posttraumatic stress. Data were collected on anonymous
questionnaires distributed on Fort Sam Houston and Lackland Air Force
Base in San Antonio, Texas, from summer 2010 to summer 2011. In order to
participate in this study, the participants must have been deployed for
at least 30 days or more, aged 18 years or older, and on active duty.
The study was reviewed and received an exempt determination from the
Brooke Army Medical Center's Institutional Review Board. For this
study, the independent variable was adult attachment (both the
categorical attachment measure (RQ) and the continuous measure of adult
attachment (see description in Attachment section below), and the
dependent variable was PTSD symptoms.

Participants

Among the 561 respondents, 403 were male, 157 female, and one no
response; 8% aged 25 years and younger, 23% in the 26 to 30 year age
range, 48.5% aged 31 to 40 years, 21% 41 years of age and over; 69%
married or living with a partner; 62% Army and 37% Air Force; 54% SGT,
SSG, or SFC; 23% LTs to CPTs *; 22% with master's degree or higher,
30% with bachelor's degree, and 44% had some college. The ethnicity
of the sample was 12.3% Hispanic and 86.6% non-Hispanic; the racial
profile was 65.6% white, 19.6% African American; 5.9% Asian/Pacific
Islander, and 8% other. All participants had deployed at least once.
Each participant reported personal total career deployment time.
resulting in an average of 1.9 years (1 year, 10.8 months), ranging from
one month to 14 years.

MEASURES

Attachment

Adult attachment was measured 2 ways: one with the Bartholomew and
Horowitz Relationship Questionnaire,33 a 4-item categorical adult
attachment variable; the other with the Fraley et al (34) Experiences in
Close Relationships [scales]-Revised, (ECR-R) which creates continuous
anxiety and avoidance attachment variables.

The conceptual relationship between the categorical measure of
adult attachment and the continuous measure is that secure adults are
low in relationship anxiety and avoidance; fearful adults are high in
relationship avoidance and relationship anxiety; the preoccupied adults
are low in relationship avoidance and high in relationship anxiety;
whereas dismissing are higher in relationship avoidance and lower in
anxiety. Shaver and Fraley (35) further developed the relationship
between these 2 self-report measures of adult attachment.

Experiences in Close Relationships-Revised (34) is a measure of
adult attachment. This is a 36-item self-report instrument designed to
measure attachment-related anxiety and avoidance. Participants are asked
to think about their close relationships, without focusing on a specific
partner, and rate the extent to which each item accurately describes
their feelings in close relationships, using a 7-point scale ranging
from "not at all" (1) to "very much" (7). Eighteen
items tap attachment anxiety and 18 items tap attachment avoidance.
Internal consistency reliability tends to be 0.90 or higher for the 2
ECR-R scales.

The Relationship Questionnaire (33) is a self-report adult
attachment measure. The measure includes a series of 4 statements that
represent secure, preoccupied, fearful, and dismissing adult attachment
styles. Participants are instructed to place a checkmark next to the
letter corresponding to the style that best describes themselves. Next
they are asked to rate each of the presented relationship styles to
indicate how well or poorly each description corresponds to their
general relationship style as measured by a Likert-type scale, from
"disagree strongly" to "agree strongly." Test-retest
reliabilities of the RQ subscales ranged from 0.49 to 0.71 as were
reported by Scharfe and Bartholomew. (36) Schmitt and colleagues (9)
validated the attachment questionnaire in 62 cultures suggesting that
people worldwide fall into one of the 4 attachment patterns, and there
are cultural differences that suggest societal norms influence
one's resulting attachment pattern.

Posttraumatic Stress Disorder Symptoms

The PTSD checklist-military, (37) commonly known as the PCL-M, is a
17-item self-report inventory that assesses the severity of each DSM-IV
([dagger])-defined PTSD symptom. Each item corresponds to the DSM-IV
diagnostic criteria for PTSD and is scored on a 1 (not at all) to 5
(extremely) scale. Previous research on the PCL-M indicated mean scores
of 64.2 (SD=9.1) for PTSD subjects and 29.4 (SD=11.5) for non-PTSD
subjects. (37) The PCL is widely used in the Department of Defense and
the Department of Veterans Affairs and has excellent reliability and
validity. (37)

DATA ANALYSIS

The data analysis was conducted using SPSS version 18 (SPSS, Inc.,
Chicago, IL). An analysis of variance (ANOVA) was used to test the first
hypothesis, which examined the relationship between the RQ and the PTSD
scores. For further analysis, the PTSD score was dichotomized creating a
categorical variable of low and high PTSD. A logistic regression was
used to test the second hypothesis, which examines the relationship
between the ECR-R and the PTSD scores.

To test the validity of using our current measures in this
population, we examined the relationship between the RQ and the ECR-R to
determine the conceptual relationship between these instruments. Using
this sample, our results were consistent with the literature. Those who
selected the secure attachment style also rated themselves as lower
avoidance and lower anxiety compared to fearful, preoccupied, and
dismissing; fearful rated themselves as higher anxiety and avoidance
than secure, preoccupied, dismissing, etc. In a separately published
article, (39) we present a more detailed discussion of the relationship
between the RQ and ECR-R.

RESULTS

Descriptive Statistics

The RQ is made up of 4 possible attachment styles: secure, fearful,
preoccupied, and dismissing. In our sample, 39.3% selected secure, 24%
fearful, 7.2% preoccupied, and 29.5% dismissing as their attachment
style. The ECR-R creates 2 measures of attachment, relationship anxiety
and relationship avoidance. The mean scores on each subscale were 2.79
for anxiety and 2.79 for avoidance with standard deviations of 1.21 and
1.15 respectively. The PTSD Score on the PCL-M ranged from 17 to 76 with
a mean of 30.23 (SD=14.40). Higher scores on the PCL-M indicate more
reported PTSD symptoms. 13% of our sample scored 50 or over on the PCL-M
whereas 33 % of our sample scored 32 or higher.

Attachment Style and Posttraumatic Stress Disorder

An ANOVA was conducted using the self-selected attachment style
(secure, fearful, preoccupied, or dismissing) as the independent
variable and the PTSD score as the dependent variable. Least squared
difference was used for the follow-on contrasts. This resulted in a
significant ANOVA, [F.sub.3501]=18.05; P< .001, and in significant
differences between all attachment styles except for the preoccupied and
dismissing styles (Figure 1). The means (M) and standard deviations for
the PTSD scores on the RQ measures resulted for secure (M=25.57,
SD=10.86), fearful (M=37.14, SD=16.28), preoccupied (M=31.83, SD=14.53)
and dismissing (M=30.24, SD=14.55).

In our second analysis, we examined diagnostic implications for
PTSD. In order to dichotomize PTSD cases, we used a cutoff of 32 on the
PCL score which is consistent with a screening threshold for this
self-report measure. A score of greater than or equal to 32 is
considered to have a higher sensitivity than the 50 or higher cutoff
traditionally seen in research. (40) Although there is some debate,
researchers recommend using a cutoff score between 30 and 34 when using
the PCL. (41)

Chi-square analysis was conducted using the dichotomous PTSD
variable of low versus high PTSD severity score. Low PTSD severity
scores included scores from 17 to 31, whereas high PTSD severity score
category included scores from 32 to 76. Twice as many individuals were
classified by having a low PTSD severity score (66.7%) as compared with
those classified as having a high PTSD severity score (33.3%). The
Chi-square analysis resulted in significant differences
([X.sup.2]=40.343, P=.000, N=502).

Figure 2 demonstrates that secure attachment produces lower
frequencies in the high PTSD severity category and the fearful style
produces the greatest frequencies, followed by preoccupied and then
dismissing. Conversely, the secure style has the greatest representation
in the low PTSD severity category.

We predicted that individuals reporting lower relationship anxiety
and avoidance would predict lower levels of PTSD scores. A t test
relationship anxiety and relationship avoidance based on whether they
were in the low or high PTSD severity category. This resulted in a
[t.sub.539]=-7.63, P [FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

COMMENT

Adult Attachment and Service Members

Descriptive statistics showed that approximately 40% of our
population of service members is self-classified as securely attached
individuals. The rest are self-classified as one of the insecure
attachment styles (ie, fearful, proccupied, dismissing). Research
outcomes supported our hypotheses that securely attached individuals
report far fewer incidences of PTSD outcomes on both categorical and
continuous measures of attachment. More severe symptoms were associated
with less functional attachment styles, and less severe with more
functional styles. These findings were strengthened by the consistency
across the two different types of attachment measurement, one a
self-reported style and the second measure a detailed description of
relationship functioning. Thus, these outcomes provide insight into both
the intrapersonal and interpersonal aspects of the attachment system as
it pertains to this population.

Our prevalence rates of PTSD when defined as scoring 50 or higher
on the PCL-M (13%) were consistent with the prevalence rates in the
literature (13%) for service members returning from the wars in Iraq and
Afghanistan. (42) Additionally, our results were consistent with the
known relationship between attachment style and PTSD outcomes in other
high-risk populations. These findings have important implications to our
military population at the individual and organizational levels.
Understanding attachment patterns and styles among service members can
possibly be both a protective factor and a diagnostic factor in
mitigating the risk of PTSD and providing treatment to service members
and their families. Additionally, attachment measures may help guide
recruitment, placement, and organizational decisions for the military.

[FIGURE 3 OMITTED]

Adult attachment style may protect service members from developing
PTSD after experiencing combat and combat-related experiences.
Attachment theory asserts that "any relationship in which proximity
to the other affects security is an attachment relationship"43 and
therefore most all professional relationships in the military impact the
individual attachment system. Moreover, an attachment relationship does
not have to be a romantic relationship and may be any relationship such
as peer to peer, subordinate to supervisor, leader to follower, or same
or mixed gender relationships. By the time a person enters the military
their propensity for certain attachment styles has been established and
may play a role in how much trust is placed in new relationships (ie,
peer to peer, leader to follower, etc). As early as basic training young
trainees are assigned a battle-buddy ** and encouraged to always have
their battle buddy with them. When assigned to a military unit,
especially in a stressful combat environment, relationships with others
within the unit are vital to enabling a cohesive effort towards a
collective goal. Many view the others within their unit as their
"military family," and are encouraged to always have a battle
buddy or a "wingman" and support each other, establishing
positive relationships throughout their career in the military, and some
even follow beyond retirement. Conversely, there are unstable
relationships within units, sometimes causing detrimental effects,
especially when individual members isolate themselves, inhibiting
communication, and consequently harming unit cohesion and effectiveness,
not only for themselves, but for their entire unit. (43)

Military personnel with secure attachments, especially with their
respective military family, appear to experience less stress because
they use social coping mechanisms. They are more apt to engage with
their families and peers, and go to mental/behavioral health
practitioners or the chaplain for assistance, all of which mitigates the
risks to developing symptoms of PTSD. Flexibility allows these securely
attached individuals to adapt well to their environment. Beyond
preventing PTSD, secure attachment may also contribute to the
reconstruction of comforting, health sustaining beliefs shattered by
trauma, an example of what Tedschi and Calhoun (44) call posttraumatic
growth. Current efforts by the military have focused on group
debriefings, psychotherapy, and psycho-pharmocological interventions.
However, additional efforts could be focused on making a more successful
match between treatment approaches so that those who are not securely
attached can receive supportive interventions that may prevent the
symptoms of PTSD. Based on these various attachment styles, providers
would be able to plan programs and provide interventions and treatments
for service members in the predeployment, deployment, or postdeployment
phases.

FUTURE DIRECTIONS

The relationship between attachment style and PTSD outcomes in
service members clearly merits further inquiry. Future studies will need
to explore the subcategories of the PTSD diagnosis with respect to
attachment styles in order to show more specifically how the attachment
system affects the disorder. More detailed information on these
relationships can guide the development of programs and interventions,
and inform the application of attachment related treatment to the
clinical context. Additionally, longitudinal studies examining the
relationship between these variables pre- and posttreatment and pre- and
postdeployment will advance the determination of causal factors, the
potential for change, and the efficacy of prevention measures. For
example, is attachment style changed by trauma or is it more of a risk
factor? If something can be done in the military to help promote secure
attachment in the interest of strengthening our forces, what could that
be and how can this be undertaken within a military setting?

** Generally defined as the person to whom a Soldier can turn in
time of need, stress, and emotional highs and lows who will not turn the
Soldier away, no matter what. This person knows what the Soldier is
experiencing because of experience with similar situations or
conditions, either current, previous, or both.

Dr Mason is Associate Director of Research Outcomes and Data
Analytics, Wellness & Prevention, Inc, Ann Arbor, Michigan. He is
also an Assistant Professor, Adjunct, Department of Psychiatry and
Behavioral Sciences, Johns Hopkins University School of Medicine,
Baltimore, Maryland.

military combat, violent personal assault (ie, sexual assault,
robbery, mugging), being kidnapped or taken hostage, terrorist
attack, torture, incarceration as a prisoner of war or in a
concentration camp, natural or manmade disasters, and automobile
accidents. (2)