Attachment and personality disorders: a short review

Attachment theory is a biopsychosocial model referring to a person’s characteristic ways of relating in close relationships, such as with parents, children, and romantic partners. These ways of relating are learned during early infancy and mold subsequent intimate relationships. An adult who is securely attached has internalized a reliable relationship to his/her caregivers in infancy, and thus is capable of adapting to different social contexts and, more importantly, of maintaining an adequate equilibrium between self-regulation and interpersonal regulation of stress. Insecure adult attachment styles are divided into 1) anxious/preoccupied (individuals are hypersensitive to rejection and show compulsive careand attention-seeking behavior); 2) Avoidant/dismissing (individuals are hyposensitive to social interactions, and are socially isolated); and 3) unresolved/disorganized (individuals are unable to cope under stress, thus suffering pervasive affective dysregulation). This review discusses the theoretical, psychological, neuroscientific, and developmental aspects of attachment from an evidence-based perspective. It provides an updated account of the science regarding attachment and its relevance to the etiology, diagnosis, and treatment of mental illness. It examines the privileged relation between attachment and personality disorders (PDs) from multiple angles in order to introduce the most recent psychotherapeutic advances, based on attachment research, for the treatment of PDs, particularly borderline PD. Three effective, Attachment and personality disorders – Lorenzini and Fonagy 2 evidence-based psychotherapeutic interventions are described: Mentalization-Based Treatment, Transference-Focused Psychotherapy and Schema-Focused Therapy. Attachment and personality disorders – Lorenzini and Fonagy 3 Introduction: Attachment and its relevance to personality disorders Attachment theory, conceived by John Bowlby (1), refers to a person’s characteristic ways of relating in intimate relationships to “attachment figures”, often one’s parents, children, and romantic partners (2, 3). From birth, the interactions of an infant with his/her primary caregivers will establish a base for personality development and will mold subsequent close relationships, expectations of social acceptance, and attitudes to rejection. A secure base is formed when the attachment figure (usually the mother) provides stability and safety in moments of stress, which allows the infant to explore his/her surroundings. Thus, the child creates a set of mental models of him/herself and others in social interactions (“internal working models”), based on repeated interactions with significant others (4). These early attachment relations are crucial for the acquisition of capacities for affect and stress regulation, attentional control, mentalization, and for the infant’s sense of selfagency (5). The attachment literature has been dominated by operationalized assessments of characteristic patterns of relating. Most influential were observations of individual differences in infants’ attachment security assessed by the Strange Situation procedure (6). When briefly separated from their caregivers and left with a stranger in an unfamiliar setting, infants show certain behavioral patterns. Three distinct attachment patterns have been identified from the application of this procedure: secure (63% of