The Psychopathological Domains of Attachment Trauma: A Proposal for a Clinical Conceptualization

Abstract

This article provides a critical review of the concept of attachment trauma, proposing an expanded definition that reflects its psychopathogenic dynamics and clinical outcomes. The first aim of the review is to define attachment trauma and differentiate it from related constructs. Attachment trauma is conceptualized as a condition emerging within primary attachment relationships, characterized by prolonged failures in caregiving and/or ongoing abuse. These relationships create recurrent, inescapable threats, leading to significant disruptions in the child’s physiological, socio-emotional, and cognitive development. The second aim of the review is to explore attachment trauma as a permeating psychopathological dimension that may underpin a broad spectrum of mental disorders manifesting in adulthood, including complex posttraumatic stress disorder, dissociative disorders, and borderline personality disorder. Recognizing attachment trauma in adults poses clinical challenges due to its complex and pervasive nature, often presenting with a constellation of symptoms across multiple domains, such as dysregulation of arousal, disintegration of higher-order cognitive processes, emotional and impulse dyscontrol, detachment and dissociative reactions, dysfunctional self and relational representations, impairments in mentalization, maladaptive compensatory strategies, and epistemic mistrust. The third objective of the review is to integrate the recognition of attachment trauma into clinical practice, emphasizing the identification of its impacts based on clinical presentation. The review highlights key therapeutic interventions, including the establishment of a safe therapeutic relationship, regulation of emotions and arousal, modification of pathogenic beliefs, addressing detachment symptoms and dissociated self-states, promotion of mentalization and epistemic trust, and the processing of both implicit and explicit traumatic memories. These interventions aim to repair the psychological damage caused by attachment trauma, fostering integration and healthier relational patterns.

But I will stretch my toes so that they touch the rail at the end of the bed; I will assure myself, touching the rail, of something hard. Now I cannot sink; cannot altogether fall through the thin sheet now. Now I spread my body on this frail mattress and hang suspended. I am above the earth now. I am no longer upright, to be knocked against and damaged. All is soft, and bending. Walls and cupboards whiten and bend their yellow squares on top of which a pale glass gleams. Out of me now my mind can pour.

Virginia Woolf, The Waves

Introduction

A substantial body of literature provides compelling evidence indicating that child maltreatment (CM) constitutes a significant risk factor across a broad spectrum of mental disorders, while also contributing to poorer prognoses and treatment resistance irrespective of diagnostic categories (Grummitt et al., 2024; Lippard & Nemeroff, 2020; McCrory et al., 2017; Teicher et al., 2022;). Furthermore, CM is associated with an increased vulnerability to several health and psychosocial problems, including cognitive impairment, heightened suicide risk, adolescent pregnancy, obesity, metabolic syndrome, coronary heart disease, certain types of cancers, and autoimmune disorders as individuals age (Ehrlich & Cassidy, 2021; Green et al., 2010; Grummitt et al., 2024; McCrory et al., 2017; Strathearn et al., 2020; U. S. Department of Health and Human Services, 2017; Dell’Acqua et al., 2025).

The World Health Organization has broadly defined CM as “acts of commission and omission by parents or caregivers that result in harm to the child” (Krug et al., 2002, p. 59). According to the most widely used definitions in clinical, public health policy, and research settings (Leeb et al., 2008; APA, 2013; Krug et al., 2002), all forms of CM involve severe and/or enduring failures of primary attachment figures to fulfill the roles of protection, nurture and development that are essential for survival and proper development in our species (Liotti, 2017; McLaughlin et al., 2017; Schore, 2009a). This condition creates a persistent state of unescapable threat, as the primary source of security for the child − the attachment figure − is also the source of danger. Therefore, we propose that, in most cases, CM should be more accurately redefined as a form of attachment trauma. Accordingly, the first goal of this review is to propose a definition of attachment trauma that better characterizes the psychopathogenic dynamics and clinical outcomes of CM.

The second aim of this review is to discuss the clinical consequences of attachment trauma as a psychopathological dimension that may permeate many patients with different mental disorders, rather than merely serving as a risk factor for specific disorders. Although severe and prolonged forms of CM (and therefore attachment trauma, according to our hypothesis) is widely acknowledged as a key contributor to various adult disorders, such as Post Traumatic Stress Disorder (PTSD), Complex Traumatic Stress Disorder (CPTSD), Borderline Personality Disorder (BPD), or Dissociative Disorders (DD) (Dalenberg et al., 2012; Ford & Courtois, 2020, 2021; Ford et al., 2022; Luyten et al., 2020), a substantial and authoritative body of evidence suggests that its impact extends beyond specific psychiatric diagnoses. Instead, CM is associated with a range of psychopathological manifestations that exacerbate symptom severity, worsen prognosis, and hinder treatment response, regardless of the diagnosed disorder and irrespective of the therapeutic approach employed (Dvir et al., 2014; Farina & Schimmenti, 2025; Farina et al., 2019; Grummitt et al., 2024; Lippard & Nemeroff, 2020; McCrory et al., 2017; Schimmenti, 2018; Teicher et al., 2022). As stated by McCrory and colleagues: "Childhood maltreatment, including physical, sexual, emotional abuse and neglect, arguably represents the most potent predictor of poor mental health across the life span […] a psychiatric disorder in an individual who has experienced childhood maltreatment is more likely to be persistent and recurrent and less likely to respond to standard treatment approaches (McCrory et al., 2017, pp. 338-339). Taking mood disorders as an example, Grummitt et al. (2024) recently calculated that the prevalence of depressive disorders causally attributable to child maltreatment is 21%. On the other hand, Lippard and Nemeroff (2020) showed that CM among patients with mood disorder is associated with heightened risk for first mood episode, increased likelihood of episode recurrence, a more severe clinical picture with greater comorbidities, increased risk for suicidal ideation, and poorer treatment response to pharmacotherapy and/or psychotherapy.

This evidence necessitates that clinicians recognize the impact of CM even in patients who do not present with a typical trauma-related disorder, to prevent ineffective treatment and patient drop-out. By transcending traditional diagnostic classifications, clinicians can more effectively grasp the clinical problems faced by individuals who have endured CM. In this regard, Teicher et al. (2022) stated that “[…] for these individuals we recommended, as a first step, a moderate revision to the DSM, to add the specifier “With Maltreatment History” or “With Early Life Stress” to their primary DSM diagnosis to recognize that these individuals are part of a distinct maltreatment-related subtype or ecophenotype” (p. 1336).

It is estimated that in the USA “one in four children will encounter child abuse or neglect during their lifetime” (Lippard & Nemeroff, 2020, p.20). Data from WHO (2006) shows that in Europe an estimated 18 million children experience sexual abuse, 44 million suffer physical abuse, and 55 million endure emotional abuse before turning 18. Severe maltreatment can be fatal, claiming the lives of over 850 children under the age of 15 each year.

Empirical evidence also reveals that parents are implicated in perpetrating such maltreatment in over 90% of cases (U. S. Department of Health and Human Services, 2017), reflecting both its widespread prevalence and its tendency to elude detection by clinicians who may be unaware of its presence in their clients. Indeed, CM − especially when it occurs in families and takes the form of attachment trauma − may not be spontaneously disclosed by patients during therapy for several reasons. For example, most forms of CM involve neglect, which can be challenging for individuals to recognize as a form of maltreatment. Additionally, traumatic experiences in attachment relationships may occur during developmental stages that precede the formation of episodic memory (Massullo et al., 2023). Furthermore, some individuals who have experienced maltreatment may view it as a normal aspect of their upbringing, given that it was ingrained in their environment; as a result, they may not consider it significant enough to mention during therapy sessions. In many cases, the presence of CM does not surface spontaneously, nor is it easily recalled by the patient. Instead, it can often be inferred from the psychopathological processes it triggers and their associated clinical manifestations, which may serve as indicators of a likely history of maltreatment (Farina & Schimmenti, 2025). Finally, we should report that a growing body of data indicates that experiences of child maltreatment and abuse, especially in early childhood, cause neurobiological alterations that lead to psychopathological vulnerability, which contributes to the clinical manifestations of CM (Nelson et al., 2025).

Therefore, the third objective of this review is to incorporate into clinical reasoning the possibility of identifying the consequences of attachment trauma based on the patient’s clinical presentation, even if related experiences are not explicitly reported. To achieve this, we will outline the pathogenetic processes activated by attachment trauma, discuss the related clinical manifestations, and examine the therapeutic challenges that arise from these factors.

The perspective we propose in this review aligns well with emerging research approaches in psychopathology, such as the Research Domain Criteria (RDoC) developed by the US National Institute of Mental Health (Cuthbert & Insel, 2013). The RDoC advocates for a necessary shift from a categorical, disease-centered model to a dimensional approach that focuses more on pathogenetic and maintaining processes of mental disorders (Luyten & Fonagy, 2018). Adopting a developmental framework could enhance our ability to identify treatment strategies tailored to the specific needs of individuals who have experienced CM (Farina et al., 2019; Karatzias et al., 2018; Schimmenti & Caretti, 2016).

The role of primary attachment figures in childhood maltreatment

Despite its clinical significance, studying the effects of CM on psychopathology presents several challenges, notably the lack of a universally accepted definition of CM and the mechanisms by which it can generate adverse effects on developmental pathways (Ford & Courtois, 2020; Isobel et al., 2017; Massullo et al., 2023). The relationship between CM and psychopathological vulnerability is influenced by several mediating factors that interact in complex ways: these factors include genetic predispositions and epigenetic changes resulting from interactions with the environment, the individual’s temperamental characteristics, subsequent developmental experiences − usually both adverse and positive − and various contextual conditions, e.g., economic hardship in the family, community violence, and environments lacking in cultural and emotional enrichment (DiCorcia & Tronick, 2011; Luyten et al., 2020).

CM is commonly categorized into child neglect − which can be emotional and/or physical − child emotional abuse, child physical abuse, and child sexual abuse (American Psychiatric Association, 2013; World Health Organization, 2006). Even though some studies propose that different types of CM may have distinct pathogenetic effects (Nelson et al., 2025; Strathearn et al., 2020), reliable research has shown that these forms of maltreatment rarely occur in isolation (US Department of Health and Human Services, 2016). Instead, there is substantial evidence that they tend to co-occur (Bifulco & Schimmenti, 2019), likely resulting in overlapping vulnerabilities in psychopathology (Vachon et al., 2015). Neglect, which accounts for approximately 75% of cases, is the most prevalent form of CM (U. S. Department of Health and Human Services, 2017): it is defined as the deprivation of ‘a stable, sensitive, and responsive caregiver, which is a species-expectant experience’ (McLaughlin et al., 2017, p. 463). Some researchers argue that neglect should be considered a fundamental component within the definition of CM, suggesting that any ongoing abuse is unlikely to occur without concurrent neglect characterized by a lack of parental protection and care (Allen, 2013; Massullo et al., 2023; Schimmenti, 2017, 2018).

Childhood is indeed a crucial stage in human development during which individuals are entirely dependent on their parental figures. Parents play a fundamental role not only in securing the child’s physical well-being through protection, nourishment, and basic care but also in promoting appropriate physiological and socio-emotional development (Bowlby, 1969/1982; Harlow & Zimmermann, 1959; Luyten et al., 2020). Like many other mammalian species, humans require a broad range of environmental interactions, particularly those involving caring relational experiences provided by caregivers during sensitive developmental periods, to thrive and achieve optimal maturation (McLaughlin et al., 2017). Indeed, for proper development, individuals need the environment (especially interpersonal) to provide specific experiences that allow for the correct maturation of nervous structures and mental functions. The human genome provides a foundational blueprint for brain development, but specific experiences subsequently are needed to properly shape neural architecture through experience-dependent plasticity during sensitive periods (Nelson et al., 2025). When there is a deviation from this relationship between genetic programming and environment, such as inadequate caregiving or exposure to a threatening environment, development is disrupted. When these expected environmental inputs are missing or insufficient due to neglect or parental failure to fulfill their roles as caregivers, protectors, and interpersonal regulators of emotions, it undermines the children’s psychobiological development, generating a threatening environment from which they cannot easily defend themselves, as their source of protection may be absent, ineffective, or itself a source of threat, leading to traumatization (Corrigan & Christie-Sands, 2020; Farina et al., 2019; Ford & Courtois, 2020; Liotti, 2017; Schimmenti, 2022a; Schore, 2009a; Teicher et al., 2022). These detrimental experiences are described using various terminologies, such as developmental trauma, complex trauma, early relational/interpersonal trauma, cumulative trauma, and attachment trauma. Each term emphasizes different aspects of these conditions (Allen, 2013; Liotti, 2017; Schore, 2009a, 2009b), but they concur in identifying the role of parental CM in the subsequent traumatic development of the child. In their comprehensive review, Isobel and colleagues (2017) aimed to clarify the commonalities and differences among these various conceptualizations of psychological trauma occurring within familial contexts. They found that despite the differing terminologies, all these concepts share a common element, namely the violation of the caregivers’ fundamental responsibilities in ensuring the child’s proper protection and development. In other words, the common element is the severe failure of the primary attachment relationship.

The clinical manifestations in adulthood derived from this parental failure sometimes closely mirrors, if not overlaps, with those that have been delineated for Developmental Trauma Disorder (DTD; Ford et al., 2022), Complex Trauma Stress Disorder (CTSD; Redican et al., 2021) and also features of Borderline Personality Disorder (BPD; Erkoreka et al., 2021). Accordingly, we propose integrating this psychopathological domain into a unified conceptual framework of attachment trauma. Accordingly, it is imperative to emphasize that what is called attachment trauma in this review is not a distinct diagnostic category, but rather an etiopathogenic condition that engenders a complex psychopathological dimension characterizing certain disorders such as CTSD, DTD, or BPD, while also exerting a pervasive detrimental influence on nearly all mental disorders, exacerbating their symptomatology, prognosis, and complicating treatment (Farina et al., 2019; Grummitt et al., 2024; McCrory et al., 2017).

Hence, a transnosographic pathogenic condition is associated with the syndromic psychopathological dimension of attachment trauma and contributes to a poorer prognosis and challenges in treatment, irrespective of the specific disorder manifested or the therapeutic approach employed. As elucidated in subsequent sections, discerning the occurrence of attachment trauma in a patient's history can sometimes be challenging. Consequently, our proposed clinical approach involves inferring the presence of attachment trauma from a specific constellation of psychopathological manifestations, clinical indicators, and therapeutic challenges, rather than relying solely on the patients’ self-reported traumatic experiences from their developmental history.

In doing so, we are aware that this approach also carries risks. Inferring attachment trauma without explicit patient reports may lead to misdiagnosis or the imposition of etiological interpretations that do not align with the patients’ actual experiences. Potentially, such assumptions could alienate patients from their personal history and could exacerbate their distress if they feel their experiences are being mischaracterized. Furthermore, premature or incorrect inferences about attachment trauma might undermine the therapeutic alliance, thus leading to therapeutic failures. However, identifying attachment trauma when it is not immediately recognized by the client serves to uncover underlying issues that significantly impact the patient’s mental health and treatment outcomes. Accordingly, ensuring that inferences are based on robust clinical evidence − as presented in subsequent sections of this review − and are sensitive to the patient’s current experience is essential to balance the benefits and risks effectively.

The construct of Attachment Trauma

The term “attachment trauma” is not a recent one, having emerged around the 1990s (Milchman, 1995; Purcell, 1996). It is currently found in over 200 scientific publications (214 in the Scopus database – information retrieved on February 2025); yet the construct still needs a clear definition. In most cases, it has been synthetically defined, as a “seriously disrupted attachment and the lack of security it produces, without repair or intervention for the child” (Ford & Courtois, 2020, p. 132), without further specification. Corrigan and Christie-Sands (2020) used the term attachment shock to indicate “attachment disruptions and relational shocks, chronic neglect, and other traumas occurring during critical periods of the brain’s maturation” (p.1). Schore (2009a, 2009b), in his influential writings on this topic, uses the terms developmental trauma, early relational trauma, and attachment trauma interchangeably, without providing a clear and distinct operational definition of these concepts. Allen was among the first who provided a more detailed definition of attachment trauma, describing it: “…in two senses: first, to refer to trauma that takes place in attachment relationships; second, to refer to the adverse long-term impact of such trauma on your capacity to develop and maintain secure attachment relationships” (2013, p. 163). Ford and Courtois (2020), while not explicitly referencing the concept of attachment trauma, delineated a very similar condition by incorporating it within the category of complex trauma. Indeed, he defined complex trauma in terms of developmentally adverse interpersonal events capable of disrupting the healthy physical and psychological development of the individual. A more articulate definition was offered by Isobel and colleagues (2017), who, through a review of the scientific literature on the topic, defined attachment trauma as follows: “Based on attachment theory and the lifelong impacts of early attachment relationships (within the first two years) on the development of self and safety (Allen, 2013; Tassie, 2015), it must occur within relationships where there is a close emotional bond and a significant degree of dependency, usually between an infant and primary caregiver, where the infant or child experiences the primary caregiver as abusive, neglectful, or emotionally unavailable. It may also occur due to adoption, parental death, or other disruptions within early childhood” (Isobel et al., 2017, p. 4). This definition offers a clear description of attachment trauma and its consequences but falls short in explaining the psychological processes underlying its origins and maintenance.

Also, Carol George (2023) broadened the understanding of attachment trauma to encompass chronic parental failure in protection, encompassing all forms of parental violence, affect dysregulation and misattunement that result in a “toxic traumatic stress” reaction in children, undermining their behavioral, representational, and neurophysiological regulation (p. 48). This perspective is consistent with attachment research showing the negative impact of parental misattunement, and not only neglect and abuse, in the child’s attachment relationships (Schuder & Lyons-Ruth, 2004), yet it comes with a recursive stance, so that attachment trauma is identifiable by the toxicity of the effects of such relationships.

On the other hand, some scholars tend to equate attachment trauma with child neglect, defined as “a general and persistent failure of the caregiver in providing a child’s basic material and/or psychological needs, limiting or impairing the adequate development of a child’s physical and mental health” (Carvalho Silva et al., 2024, p. 2). As appropriate as this equation seems, it does not include other active forms of maltreatment perpetrated by caregivers.

Very recently, Zagaria and colleagues (2024) provided an integrative review examining attachment and trauma studies with the purpose of providing a comprehensive definition of attachment trauma. They defined attachment trauma as “varying and long-lasting biological, psychological, and relational consequences resulting from incomplete encoding and integration of emotionally overwhelming experiences within an attachment relationship” (p. 1). This definition is interesting, as it attempts to capture the complexity of the phenomenon, yet it tends to suffer from vagueness, causal ambiguity, and reductionism. For example, the definition suggests a causal relationship between incomplete encoding of traumatic experiences in attachment relationships and its biological, psychological, and relational consequences. Especially, this notion of “incomplete encoding” is particularly problematic, as it implies a specific cognitive process without explaining how this process is linked to the wide range of consequences described. Also, what constitutes “incomplete encoding” or “emotionally overwhelming experiences” can vary widely across individuals and contexts, leading to potential inconsistencies in diagnosis and treatment. The definition may thus be critiqued for reducing complex phenomena to the process of “incomplete encoding” and lack of integration. Yet, attachment trauma is a multifaceted process involving biological, psychological, social, and relational dimensions, and reducing it to cognitive processes risks oversimplifying the phenomenon. In other terms, the definition presupposes a particular epistemological stance that partly aligns with cognitive and developmental psychology, where trauma is framed in terms of encoding and integration of experiences. This stance may not fully account for alternative epistemological perspectives, such as those found in psychoanalysis, which emphasizes the interpretative, affective, relational, and contextual aspects of trauma differently (Schimmenti & Caretti, 2016).

Building upon the insights of these and other scholars, we offer the following definition of attachment trauma:

Attachment trauma is a condition that emerges within primary attachment relationships, in which prolonged and severe failures in protection, regulation and caregiving, and/or the occurrence of active and ongoing abuse, represent lasting or recurrent threats from which the child is unable to escape. This includes prolonged and severe affective, attentional, cognitive, motivational and neurovegetative misattunement in relational exchanges with neglectful and/or abusive parental figures that impede or hinder the child’s normative physiological, socio-emotional, and representational development.

It is imperative to emphasize that the absence of crucial components essential for a child’s survival, including protection, nourishment, and fundamental care, coupled with the lack of support for appropriate physiological and socio-emotional development, must be acknowledged as a significant threat. These functions are deemed indispensable for the proper development of a human being and are thus considered species-expectant experiences (Allen, 2013; DiCorcia & Tronick, 2011; Ford & Courtois, 2020; McLaughlin et al., 2017). These serious shortcomings in fulfilling the main functions intrinsic to primary attachment relationships, that is, safety and security (Bowlby, 1969/1982) possess a traumatic essence. The severe and prolonged failure of parents to fulfill their innate roles of providing protection, essential care, and fostering the development of regulatory processes engenders an inescapably threatening environment in which the child feels powerless (Farina et al., 2019; George, 2023; Schimmenti & Caretti, 2016; Solomon & George, 2011). It might be crucial to recall here some essential characteristics of traumatic experiences: a) they entail a state of threat, which can be a single event or prolonged; b) they are, at least at some point, inescapable; c) they overwhelm the individual’s capacity for resilience; d) they induce a sense of powerlessness; e) they are more severe when perpetrated by other humans and involve close relationships; and f) they have more pathogenic effects if they occur during early developmental stages (Herman, 1992; Van der Kolk, 2007; Ford & Courtois, 2020). Thus, both the profound and protracted failure in caregiver’s protection, care, and regulation (neglect) and the active abuse constitute a traumatic condition, given the child’s fundamental dependence on these provisions from their parents for survival and healthy development (George, 2023; Schimmenti, 2022a; Isobel et al., 2017; Ford & Courtois, 2020).

Paradoxically, this condition also alters the ability to respond to stress and threats, generating a vicious cycle of emotion dysregulation (DiCorcia & Tronick, 2011; Tronick et al., 2021). In a similar vein, several scholars have pointed out that attachment trauma causes a “double liability” (Allen, 2003, 2013; Fonagy & Target, 1997): on the one hand, it triggers stress and threat responses and has a dysregulating effect on emotion and behavior; on the other hand, it prevents the proper development of mature self-regulatory and coping mechanisms by impairing the capacities of mentalization and trust in relying on subsequent caring relationships (as in the case of the therapeutic relationship).

Indeed, extensive research has consistently demonstrated that even prolonged periods of cognitive, affective, and neurovegetative disharmony with a unresponsive or dysregulated caregiver, stemming from many factors such as grief or coping with significant life challenges like illness or marital conflicts, may represent a pervasive and inescapable threat that can lead to enduring alterations and compromise emotional, cognitive, and social development (Adenzato et al., 2019; Corrigan & Christie-Sands, 2020; DiCorcia & Tronick, 2011; Fonagy et al., 2023; Guérin-Marion et al., 2020; Luyten et al., 2020; Massullo et al., 2022; McLaughlin et al., 2017; Schore, 2009; Tronick et al., 2021).

It is also important to underscore that parental failures in providing protection and regulating emotional and behavioral responses may consequently heighten the child’s susceptibility to further and later traumatic experiences or risky situations beyond the family environment, extending into subsequent developmental phases such as adolescence and early adulthood (Massullo et al., 2022; Schimmenti, 2018). For instance, episodes of severe neglect can result in young victims being unable to safeguard themselves in difficult interpersonal scenarios, thus rendering them vulnerable to abuse by peers or adults outside the family (Granieri et al., 2018; Herman, 1992). Additionally, such neglect may predispose individuals to substance abuse (Schimmenti et al., 2022, 2025) or engage in early and indiscriminate sexual activity (Ford & Courtois, 2020; Strathearn et al., 2020). Furthermore, adaptation to abusive interpersonal dynamics within attachment relationships may foster a propensity to endure emotionally abusive relationships in adulthood, as evidenced in cases of intimate partner violence (Speranza et al., 2022). As elucidated by Ford and Courtois (2020), these supplementary components of this maladaptive developmental trajectory often engender persistent risks for polyvictimization and revictimization, perpetuating a cyclic exacerbation of psychopathological vulnerability and associated clinical conditions.

Attachment trauma does not overlap with disorganized attachment

Although the constructs of attachment trauma and disorganized attachment (DA) are strongly related (Buchheim et al., 2008), it is necessary to distinguish them. DA is a construct originating from an experimental paradigm and refers to observations of children exhibiting inconsistent patterns of approach toward their caregiver during the Strange Situation Procedure (SSP). This construct was later applied to identify unresolved states of mind in adults during the Adult Attachment Interview (AAI) (Main et al., 2003-2008).

In the SSP, the patterns of behaviors of DA are characterized by rapid and apparently unmotivated shifts between approaches and distancing behaviors, sometimes even manifesting simultaneous tendencies to approach and withdraw. Such incoherent behaviors suggest the involvement of multiple, disjointed centers of initiative and meaning, none of which are inhibited − as in conflict − and none of which are integrated with one another into a cohesive resolution (Liotti, 1992; Main & Hesse, 1990; Main & Solomon, 1986).

During the SSP, children exhibiting DA sometimes displayed behaviors such as estrangement, immobility, or absence. This prompted some scholars to propose that the mental state of children with DA during separation from and reunification with their caregiver resembled the freezing response characteristic of passive defense and dissociative states observed in adult patients (Liotti, 2004; Lyons-Ruth et al., 2006). Additionally, there has been speculation, supported to some extent by empirical findings, that the relational experiences of children with DA, characterized by caregivers serving as both sources of safety and threats, give rise to deeply conflicting internal working models of attachment (the unconscious mental representations containing the cognitive and affective schemata of self, others, and relationship between self and others; see Bowlby, 1973). These contradictory representations are posited to serve as a precursor to dissociative compartmentalization (Dutra et al., 2009; Liotti, 1992; Ogawa et al., 1997; Schimmenti et al., 2022a).

Empirical research has also indicated that parents of children with DA often exhibit abusive and neglectful behaviors (Farina et al., 2019). Furthermore, several studies utilizing the Adult Attachment Interview (AAI; George et al., 1987) have demonstrated a significant association between unresolved loss or trauma in the caregivers’ memory and DA in their offspring (Main & Hesse, 1990). Additional research has revealed a link between childhood DA and caregiver mental states characterized by either overt hostility or helplessness. Notably, in both scenarios of hostility and helplessness, caregivers are prone to abdicating their protective and nurturing roles (Lyons-Ruth et al., 2006). Furthermore, several studies have identified significant predictors of DA, including insensitive maternal behavior, neglect, atypical behaviors, active child maltreatment, and maternal psychiatric disorders (Lyons-Ruth & Jacobvitz, 2008). The disorganization of mental states during attachment interactions may arise from mothers experiencing fear or disorientation while caregiving, leading to frightening or neglectful behavior toward their infants (Main & Hesse, 1990). Specifically, mothers struggling with emotion dysregulation during interactions with their infants may be particularly susceptible to engaging in such behaviors, thus heightening the infants’ feelings of threat (Leekers et al., 2017).

It is important to note that recent research findings suggest that although DA can be likened to a form of early traumatization, it remains a construct originating from experimental procedures that does not necessarily indicate child maltreatment. The inconsistent behaviors leading to the DA classification may have other contributing factors besides those dependent on the quality of relationships with parents (Granqvist et al., 2017). Furthermore, according to meta-analytical reviews of the longitudinal studies focusing on the consequences of early attachment, all patterns of insecurity undermine biological responses to stress, affect, and behavioral regulation, as well as children’s interpersonal and social competence: in this context, the role of DA as a precise predictor of externalizing and internalizing psychopathology is somewhat limited (Cassidy, 1994; Roisman & Groh, 2021). Additionally, some studies suggest the existence of a vicious cycle in which attachment insecurities contribute to future psychological disorders, which in turn additionally increases attachment insecurities, thus maintaining or exacerbating the disorders over time (Mikulincer & Shaver, 2021). Finally, recent studies on early attachment relationships indicate that individual differences in childhood attachment behavior are more consistent with a dimensional rather than categorical model, and indicators of disorganization and ambivalence overlap as they are based on a common latent factor (Roisman & Groh, 2021). In essence, empirical studies on attachment cannot definitively establish a precise correspondence between the different patterns detected in experimental settings and the various forms of psychopathology, as both are influenced by complex trajectories involving not only early childhood experiences but also genetic predisposition and other intertwined factors (Gunnar & Quevedo, 2007; van IJzendoorn et al., 2021).

In essence, DA is better represented as an internal configuration of severe attachment failures involved in the child-caregiver interactions, whereas attachment trauma can be better conceptualized as the potentially pathological process stemming from the consequences of these interactions. However, while directly applying results from studies on insecure attachment and DA to clinical research may be inappropriate, they nonetheless provide crucial evidence for understanding the different pathogenetic processes related to severe caregiver failures that lead to attachment trauma and other trauma-related disorders. Therefore, the subsequent sections will briefly explore the pathogenic dynamics of DA that contribute to the psychopathological dimensions of attachment trauma.

Difficulties in recognizing attachment trauma

One of the most significant clinical challenges concerning attachment trauma lies in its frequent underestimation or complete oversight by some clinicians. A contributing factor to this phenomenon is the prevailing misconception among many practitioners that child maltreatment predominantly involves instances of active abuse, overlooking the prevalence of neglect, which constitutes the majority of cases (Carvalho Silva et al., 2024; Massullo et al., 2023; McLaughlin et al., 2017). Indeed, a considerable portion of child maltreatment involves significant and enduring deficiencies in care or appropriate emotional attunement, often remaining undisclosed by patients due to its nature as an experience of absence that may go unnoticed and unreported during clinical discussions (Stoltenborgh et al., 2013). Furthermore, approximately a quarter of these experiences appear to occur before the age of three, thus preceding the formation of autobiographical memory narratives that can be captured in medical histories (U. S. Department of Health and Human Services, 2017). For instance, consider a scenario where a mother faces personal adversities such as loss, separation, or illness during the first two or three years of her child’s life but subsequently regains stability. While the painful and traumatic experience may not be retained in the child’s explicit autobiographical memory, especially if negative events have been overcome, its traces may persist in bodily, implicit memories, as well as in the incomplete and impaired development of mental functions heavily reliant on the attachment relationship (Corrigan & Christie-Sands, 2020; Farina et al., 2019; McLaughlin et al., 2017; Luyten et al., 2020; Schore, 2009b).

Even when biographical elements are recalled, certain forms of maltreatment may go unrecognized, such as overprotection, which can be simply perceived as a venial excess of care (Farina et al., 2021). Recent research suggests that parents’ excessive preoccupation in interactions with their children, characteristic of attachment trauma, may also manifest as hypervigilant, alarmed and overprotective behaviors, reaching levels akin to active maltreatment and neglect (Farber et al., 2019; Vergara-Lopez et al., 2016).

Moreover, identifying the presence of attachment trauma in the developmental history of adult patients can be challenging due to the absence of reliable psychometric instruments. Self-administered questionnaires, though expedient and cost-effective, may fail to capture less overt manifestations of attachment trauma (Imperatori et al., 2022). Even gold-standard, behavior-based interviews like the Childhood Experiences of Care and Abuse (Bifulco et al., 1994), which have demonstrated good reliability and validity, including independent corroboration of memories of neglect and abuse (Bifulco et al., 1997), have limitations in assessing preverbal, forgotten, or biased childhood experiences and memories (Bifulco & Schimmenti, 2019).

Also, the lack of a linear relationship between biographical elements of attachment experiences and psychopathological vulnerability, owing to the influence of other developmental factors such as genetic predisposition and epigenetics, further complicates the recognition of the pathogenic role of attachment trauma. Consequently, the challenge in obtaining direct evidence of inadequate caregiving from patients necessitates a shift in diagnostic processes and clinical reasoning. In some instances, inferring the presence of attachment trauma in the patient’s history becomes necessary based on the dimensional characterization of psychopathological manifestations contributing to the clinical case presentation, alongside associated therapeutic challenges. The following sections will therefore examine these pathogenetic processes, the resulting psychopathology, and the related therapeutic challenges that may serve as indicators of the likelihood of attachment trauma.

Clinical consequences of attachment trauma and related treatment difficulties

Among the common psychopathological factors that limits the proper functioning of therapy in patients with attachment trauma are alterations in autonomic arousal, difficulties in regulating emotions and impulses, states of detachment and dissociative compartmentalization, relational difficulties (including challenges within the therapeutic relationship), pathogenic beliefs of helplessness and powerlessness, maladaptive compensatory strategies, epistemic mistrust and impairments in mentalizing abilities (Farina & Schimmenti, 2025; Farina et al., in 2025; Farina et al., 2019; Luyten et al., 2020; McCrory et al., 2017; Schimmenti et al., 2025). To promote a comprehensive understanding of the psychopathology linked with attachment trauma, we will examine its pathogenic processes and consequent clinical manifestations in the following subsections. However, these processes are inherently interconnected, sometimes overlapping and mutually reinforcing, ultimately shaping individuals' susceptibility to psychological disorders and their negative therapeutic responses.

a) Dysregulation of arousal and other biological regulatory systems

Attachment trauma significantly affects the regulation of biological systems, which has profound implications for individuals’ well-being. The primary attachment relationships play a pivotal role in fostering the harmonious development of neurovegetative and other biological regulatory systems, crucial for effectively coping with environmental challenges, particularly in distressing circumstances (Corrigan & Christie-Sands, 2020; DiCorcia & Tronick, 2011; Gander & Buchheim, 2015; Gander et al., 2022; Gunnar & Quevedo, 2007; Lahousen et al., 2019). The attachment motivational system is responsible for modulating stress hormone levels and restoring vegetative balance by seeking proximity to a responsive caregiver, thereby facilitating the interpersonal regulation of stress during challenging situations (Dana, 2018; Leerkers et al., 2017). However, when caregivers fail to provide adequate emotional, cognitive, and physiological attunement, or when they experience emotional or vegetative dysregulation due to various stressors, the restoration of vegetative balance in the child is impeded. This compromised state can lead to disruptions in self-regulatory responses, disturbances in physiological, vegetative, and somatic growth, and exacerbation of pre-existing difficulties in emotion regulation. In some cases, individuals may also resort to substance abuse as a way of coping with such difficulties (Schimmenti et al., 2022, 2025), further complicating their ability to achieve balance and stability (Corrigan & Christie-Sands, 2020; Costanzo et al., 2023; Dana, 2018; DiCorcia & Tronick, 2011; Gander et al., 2022; Guerin-Marion et al., 2020; Leerkes et al., 2017; McLaughlin et al., 2017).

Empirical studies have also demonstrated that the traumatic relationships with caregivers during childhood may disrupt the child’s regulation of arousal. For instance, Oosterman et al. (2010) found that children with experiences of neglect and showing DA exhibited pathological overactivity of the adrenergic system in response to stress and environmental challenges during the SSP. When caregivers fail to effectively modulate physiological arousal, even in moderately stressful situations, it can result in reduced or disproportionate activation of the stress-response system and neurovegetative reactions. Costanzo et al. (2024) explain indeed that attachment trauma shapes affective processing through non-smooth state transitions, where affective saturation due to intense emotions leads to abrupt shifts in autonomic arousal, reinforcing cycles of hyperactivation and collapse. This has significant implications for the development of emotional, behavioral, and cognitive dysregulation, as well as detachment and compartmentalization responses (discussed in subsequent sections). Notably, these responses can be especially activated within relational contexts, including the therapeutic relationship, where the attachment system with its related, traumatized internal working models of attachment are engaged towards the therapist. In a study by Farina et al. (2015), adults with DA initially displayed no significant differences compared to a control group in a baseline situation. However, after discussing their attachment experiences during the AAI, the DA group exhibited clear signs of arousal dysregulation, indicating an intensified response triggered by the retrieval of childhood attachment experiences.

In a comprehensive review, Lyons-Ruth and colleagues (2006) stated, “The infant whose caregiver has been unable to provide basic regulation around fearful arousal fails to develop a coherent attachment strategy for reducing physiologic arousal in the face of moderate stress, leading to under- or overactivity in the stress-response system” (p. 9). Altered vegetative balance not only disrupts sleep, mood, and other regulatory functions but also exacerbates the already impaired regulation of emotions and impulses in individuals affected by attachment trauma.

Additionally, heightened vegetative arousal inhibits cognitive control and metacognitive regulation abilities (Carbone et al., 2024; Young et al., 2017). This circular process compromises relational abilities and undermines therapeutic efficacy (Leerkers et al., 2017; Lyons-Ruth et al., 2006). When manifested within the therapeutic relationship due to the activation of the attachment system with its − sometimes implicit¬ − traumatic relational memories, it further impairs the already compromised cognitive and reflectivity functions of patients, thus complicating treatment (Farina & Meares, 2022; Lahousen et al., 2019; Mayes, 2006). Consequently, relaxation and arousal management techniques, particularly those employed in body-centered therapies such as sensorimotor psychotherapy (Ogden et al., 2006), have been introduced in various forms of attachment trauma-focused psychotherapy.

Alterations in biological regulatory systems resulting from attachment trauma have been also associated with an increased risk of various medical conditions, including autoimmune diseases, coronary artery disease, metabolic syndromes, obesity, hypertension, and certain types of cancers (Hughes et al., 2017; Strathearn et al., 2020; Troisi, 2020). The well-documented relationship between attachment trauma and somatoform disorders, such as sexual and urinary dysfunctions, pain syndromes, tinnitus, colitis, parasomnias, and pseudo-neurological syndromes, further underscores the impact of attachment trauma on patients’ lives, impairing their quality of life and exacerbating relational difficulties and pathogenic beliefs, thus hindering response to treatment (Le et al., 2021; Mysliwiec et al., 2018; Romeo et al., 2022; Sar et al., 2004; van der Kolk et al., 1996; Weber & Wetter, 2022).

b) Traumatic disintegration

When child maltreatment persists over time and occurs within interpersonal contexts, it may initiate distinct pathogenic mechanisms across various levels of mental functioning, resulting in alterations in psychological integration and inhibitory control functions (Deco et al., 2015; Girgenti et al., 2021; Gordon et al., 2018; Lord et al., 2017; Ohashi et al., 2017; Park & Friston, 2013). Human brain function relies on a delicate balance between segregation and integration, crucial for coordinating efficient local processing and expansive global communication of neural information, thereby forming the basis for all mental functions (Deco et al., 2015; Duschinsky & White, 2020; Fukushima & Sporns, 2020; Lord et al., 2017). The emergence of complex mental functions and adaptive behaviors stems from the dynamic interplay among organized neural networks spanning multiple brain regions, rather than originating solely from isolated anatomical structures (Gordon et al., 2018; Park & Friston, 2013). Integration and segregation are not specific mental functions; rather, they are inherent emergent qualities essential for optimal mental operations. As noted by Janet more than a century ago, “mental health is characterized by a high capacity for integration” (Janet, 1889, p. 460).

The equilibrium between excitatory and inhibitory neurotransmission, particularly within structures like the prefrontal cortex, amygdala, hippocampus, and other limbic regions, is critical for executive functions, working and declarative memory, emotion processing and regulation, social interactions, fear responses, behavioral regulation, advanced cognitive functions, mentalization, continuity of self-experience, state of consciousness, and self-consciousness (Farina & Meares, 2022; Ferguson & Gao, 2018; Lord et al., 2017). However, integration and segregation do not unfold as predetermined biological inevitabilities; rather, they evolve through a developmental trajectory reliant upon a supportive relational foundation, characterized by a deep connection with a caregiver who embodies sensitivity, responsiveness, and reflective functioning (Fonagy & Target, 1997; Luyten et al., 2020; Meares, 2012; Winnicott, 1965). Accordingly, neuroscientific investigations have consistently demonstrated direct links between maternal sensitivity and the establishment of optimal connectivity among distinct brain regions crucial for emotional regulation and socio-emotional functioning (Rifkin-Graboi et al., 2015).

On the contrary, attachment trauma hinders the natural progression of mental integration, segregation, and inhibition due to the deleterious effects of catecholamines, corticosteroids, and persistent inflammatory responses (Carlson et al., 2009; Farina & Meares, 2022; Farina & Imperatori, 2024; Gunnar & Quevedo, 2007; Weems et al., 2019). Consequently, neurobiological dysfunctions triggered by neglecting and abusing attachment experiences may lead to alterations in both structural and functional connectivity, disrupting the architecture of local and large-scale neural networks and disturbing the delicate balance between integration and segregation (Adenzato et al., 2019; Akiki et al., 2018; Carbone et al., 2022, 2025; Girgenti et al., 2021; Lanius et al., 2020; Massullo et al., 2022; Teicher et al., 2016; Terpou et al., 2020).

This process of traumatic disintegration essentially occurs with dysregulation of emotion and behavioral control systems, with consequent mental disorganization. It also manifests with a diverse range of psychopathological symptoms depending on the specific mental functions impaired. Mental functions that rely on sophisticated mental integration, coordination and inhibition, driven by environmental interactions, particularly interpersonal ones, are especially vulnerable to traumatic disintegration (Carlson et al., 2009; Farina & Imperatori, 2024; Farina & Meares, 2022; Scalabrini et al., 2020). Neuroscientific studies consistently demonstrate the relationship between connectivity alterations and the outcomes of traumatic childhood experiences, such as difficulties in emotion and behavior regulation, impulse control failures, disturbances in self-referential processes, alterations in consciousness states, and metacognitive impairments. Specifically, the diminished integrative capacity developed during childhood disrupts the coherence of self-experience and the continuity of self, as well as the organization of mental states. This leads to fragmented self-experiences, marked by shifting self-states, chaotic behaviors, a painful sense of incoherence, emptiness, episodes of blankness, and a loss of self-intimacy, along with difficulties in mentalization (Carlson et al., 2009; D'Agostino et al., 2020; Farina et al., 2018; Farina & Meares, 2022; Putnam, 1997; Sar, 2017).

The dysregulatory and disorganizing psychopathology that emerges from the disintegrative trauma process can manifest itself dimensionally in all patients with an attachment trauma history, but it can be considered a primary pathogenetic process underlying borderline personality disorder (Farina & Meares, 2022; Meares, 2012). Additionally, traumatic disintegration serves as a predisposition that facilitates dissociative compartmentalization, further exacerbated by arousal hyperactivation (Scalabrini et al., 2020; Young et al., 2017).

Multiple neuroimaging investigations revealed that connectivity alterations observed in traumatized patients persist during the resting state as a trait of vulnerability (Lutz et al., 2017; Misaki et al., 2018). Moreover, extensive research indicates that functional connectivity further deteriorates following emotional stress or activation of traumatic memories (Adenzato et al., 2019; Carbone et al., 2024; Farina et al., 2014; Massullo et al., 2022). It is important to recognize that intense emotional activation resulting from poor emotion modulation can create a vicious cycle, in which unregulated emotions lead to cognitive disintegration; this disintegration further worsens the ability to regulate emotional states, which in turn exacerbates difficulties in cognitive integration. As a result, heightened hyperarousal intensifies disintegration, amplifying challenges in emotional and impulse control, metacognitive monitoring, and relational functioning (Farina et al., 2019).

For these reasons, the use of some psychotropic drugs has been proposed that can modulate the effects of altered connectivity (Carbone et al., 2025). In addition, in recent decades, several neuromodulation techniques have been developed that, combined with other psychotherapeutic protocols, aim to stimulate integration at the neurophysiological level by promoting functional connectivity (Lieberman et al., 2023; Nicholson et al., 2017).

The disintegrative effects of attachment trauma are deeply intertwined with the other pathogenetic processes discussed in this section, exacerbating the psychopathological vulnerability of individuals exposed to such trauma and complicating their treatment.

c) Dysregulation of emotion and impulse control

Emotional dysregulation is increasingly recognized as a trans-nosographic psychopathological dimension present in all psychiatric disorders and is associated with a worse prognosis and a range of negative outcomes, including impaired interpersonal relationships, hindrance to daily functioning, impulsivity, decreased metacognitive functions, and increased susceptibility to comorbid disorders such as risk behaviors, suicide attempts, and addictions (Aslan et al., 2024; Caramassi et al., 2022; Dell'Acqua et al., 2025; Sharma et al., 2021). On the other hand, a strong experts’ consensus underscores dysregulation of emotion and impulses as a central factor in the psychopathological consequences of attachment trauma. Consistently, emotional dysregulation is a diagnostic criterion for all trauma-related disorders, especially developmental ones (Cicchetti & Toth, 2005; D'Andrea et al., 2012; Gruhn & Compas, 2020; Luyten et al., 2020; Mosquera et al., 2014; Spinazzola et al., 2018). Furthermore, it has been empirically tested that emotional dysregulation is one of the mediating factors between problems in early attachment and the onset of several psychiatric disorders (Cloitre et al., 2008).

Emotion dysregulation is defined as “a pattern of emotional experience and expression that interferes with appropriate goal-direct behavior” (Beauchaine, 2015, p. 876), and consists of the failure of “the extrinsic and intrinsic processes responsible for monitoring, evaluating, and modifying emotional reactions, especially their intensive and temporal features, to accomplish one’s goals” (Thompson, 1994, p. 27). This involves emotional arousal regulation; emotional clarity, awareness, and acceptance; the capacity to control impulsive behaviors when experiencing negative emotions; the ability to choose contextually suitable emotion regulation strategies in order to meet personal goals and situational demands (Gratz & Roemer, 2004; Thompson, 1994).

Research has consistently demonstrated a positive association between attachment security and children's ability to regulate their emotions (Chan et al., 2023; Cloitre et al., 2008; van Dijke & Ford, 2015). Primary attachment relationships play a crucial role in fostering the development of each component involved in the regulation of emotions and impulses (Eilert & Buchheim, 2023). Attachment figures who consistently show acceptance, comfort, sensitivity, and warmth in response to their children's emotions, especially during times of distress, foster the development of adaptive emotion regulation skills (Cassidy, 1994; Chan et al., 2023; van Dijke & Ford, 2015). These skills encompass both effective behavioral strategies and cognitive understanding of emotions, circularly contributing to a secure attachment between a parent and a child. On the contrary, the failure of this regulatory role in attachment trauma results in a complex interplay of pathogenetic processes involving emotion regulation and impulse control (Cloitre et al., 2008; Corrigan & Christie-Sands, 2020; Lyons-Ruth et al., 2006; van Dijke et al., 2013). This complex interplay involves multiple factors, such as arousal dysregulation and impairments in top-down control of executive functions due to disintegration, as previously discussed. It also includes an exaggerated perception of, and heightened reactivity to, interpersonal threats, such as fears of abandonment or feelings of being devalued. Additionally, it involves secondary attachment strategies based on distancing or control, the surfacing of implicit traumatic relational memories laden with fear and anger, and pathogenic beliefs that erode self-worth and contribute to feelings of defenselessness or recalling past abuse. Furthermore, it encompasses a specific difficulty in metacognitive monitoring, which hinders the ability to reflect on and regulate one’s own thoughts and emotions (Carlson et al., 2009; Eilert & Buchheim, 2023; Fonagy & Target, 1997; Lahousen et al., 2019; Linde-Krieger et al., 2022; Liotti & Farina, 2016; Luyten et al., 2020; Schimmenti, 2022a; van Dijke & Ford, 2015; Winnicott, 1965).

Therefore, emotion dysregulation associated with attachment trauma encompasses several specific difficulties. It involves difficulties in emotional processing, where individuals may struggle to accurately identify and manage their feelings. This dysregulation often manifests as an overwhelming intensity of emotions, characterized by under-regulation of emotions in situations related to fears of abandonment, but it may also manifest with an over-regulation of emotions, fear of intimacy, and even alexithymia, where individuals have difficulty identifying and describing their emotions and using them as a guide for behaviors (Schimmenti & Caretti, 2016). Additionally, these individuals may exhibit impulsive or exaggerated behavioral responses as a result of their emotional difficulties. Problems with executive behavioral control are also common, affecting the ability to plan, make decisions, and regulate actions. Emotion detachment and alexithymia further contribute to the difficulty in connecting with and understanding one’s own and others’ emotional state. Moreover, individuals may engage in maladaptive strategies to manage their emotions, including non-suicidal self-injury, sexual promiscuity, substance abuse (such as alcohol and drugs), and eating disorders (Costanzo et al., 2023; Krause‐Utz, 2022; Lahousen et al., 2019; van Dijke & Ford, 2015; Wolff et al., 2016).

The behavioral consequences of emotional dysregulation and related maladaptive strategies are considered risk factor for the development and maintenance of psychopathology, in particular anxiety and mood disorders (Chan et al., 2023), substance abuse (Wolff et al., 2016), eating disorders (Vaydich et al., 2022), and dissociation (Hébert et al., 2020; Lyons-Ruth et al., 2006). For example, there is evidence that substance abuse can serve as an emotion regulation strategy by pharmacologically altering one's emotional state (Wolff et al., 2016). Moreover, emotion dysregulation reinforces the relational problems and pathogenic beliefs of individuals with attachment trauma histories, worsening the clinical picture and generating treatment resistance (Contardi et al., 2016; Farina et al., 2019; van Dijke & Ford, 2015). In this regard, Cloitre and colleagues (2008) showed in a clinical population that attachment trauma diminished the capacity for negative emotion regulation and reduced the expectations of support from others, regardless of the psychiatric diagnosis, leading to psychotherapeutic difficulties. Indeed, dysregulation of emotion and impulses hinders or even prevents the effective use of therapeutic techniques and strategies usually applied in the treatment of several disorders and hampers the therapeutic alliance, negatively compromising the therapeutic relationship (Liotti & Farina, 2016; van Dijke et al., 2013).

d) Detachment reactions

In the presence of overwhelming emotional burdens or the feeling of helplessness generated by traumatic events, detachment reactions often emerge as prominent responses, characterized by subjective sensations of disconnection from one’s own self (depersonalization) or from the external environment (derealization), often accompanied by an unsettling perception of unreality (Holmes et al., 2005). While clinicians commonly categorize detachment states under the umbrella of dissociation, psychopathological considerations, clinical observations, and research findings suggest that the underlying pathogenic processes for detachment may diverge from those deriving from proper dissociation and compartmentalization (Butler et al., 2019; Ellickson-Larew et al., 2020; Mazzotti et al., 2016; Rodewald et al., 2011; Steele et al., 2022). Dissociative compartmentalization arises from a blend of integrative vulnerabilities and exposure to exceedingly conflicting attachment experiences. In contrast, detachment states likely originate from innate biological passive defenses, corresponding to those of inescapable threat in mammals (Nijenhuis et al., 1998), evolved to mitigate the potentially incapacitating impacts of overwhelming and intense emotions in threatening scenarios (Ciaunica et al., 2022; Dewe et al., 2018; Nijenhuis et al., 1998). Notably, detachment responses and symptoms can also surface in individuals subjected to exceptionally distressing situations but not suffering from trauma-related disorders (Brown, 2006; Holmes et al., 2005).

Some scholars speculate that an excessive recourse to the protective mechanism of detachment during traumatic development can evolve into an overused automatic strategy even in adulthood (Lanius et al., 2006; Lebois et al., 2020; Steele et al., 2022; van der Hart, 2021). Attachment trauma exposes the child to a state of fright without solution (Main & Hesse, 1990) in the relationship with the caregiver, since the caregiver is at the same time the source of danger and potential safety, thus evoking feelings of helplessness and powerlessness that subsequently drive detachment reactions as an automatic and passive defense strategy (Corrigan et al., 2022; Kearney & Lanius, 2022). Moreover, mismatches in affective and neurovegetative responses stemming from neglect, abuse, or even hyperaroused and dysregulated caregiving impair the infant’s neurovegetative system and neurobiological stress response, giving rise to maladaptive emotion regulation strategies that can foster the automatic adoption of detachment responses (Laoide et al., 2018; Tibubos et al., 2018). Extensive clinical and neuroscientific studies suggest that detachment symptoms are significantly associated with severity of clinical presentations and negative treatment responses (Lebois et al., 2020; Lyssenko et al., 2017). The treatment of detachment states also requires different strategies than the dissociative compartmentalization, such as the application of grounding techniques, modulation of arousal, and prevention of detachment triggers (Mazzotti et al., 2016; Steele et al., 2022).

e) Exposure to contradictory interpersonal experiences and dissociation

Attachment research suggests that children classified as disorganized in the SSP often experience deeply paradoxical self-other dynamics. When caregivers exhibit neglect, helplessness, fearfulness, hyperarousal, or overt hostility, which are alarming to the child, this generates a confusing internal scenario. In this context, the caregiver who should be the source of comfort and solace simultaneously becomes the source of fear, even in the absence of overtly abusive behavior. Coined as “fright without solution” by Main and Hesse (1990), this condition encapsulates infants being ensnared in a disconcerting cycle where they are unable to escape from their caregiver nor approach them for relief from fear. Exposure to simultaneous − or rapidly alternating − incompatible activations of the attachment system (such as those concerning the approach to and avoidance of the caregiver) can lead to the formation of mutually contradictory relational schemata, which contribute to the development of divergent, incoherent, and often conflicting implicit representations of self and others that subsequently influence future relationships (Liotti, 2017; Schimmenti, 2022; Schimmenti & Caretti, 2016). Longitudinal research studies have indeed provided evidence that children classified as disorganized in their infant attachment are more susceptible to dissociative compartmentalization than organized controls (Dutra et al., 2009).

These conflicting representations, formed during early childhood, operate at an implicit level shaping the ongoing understanding of interpersonal relationships, thus contributing to relational problems and dissociative compartmentalization throughout life (Amini et al., 1996; Liotti & Farina, 2016; Lyons-Ruth, 1998). Accordingly, attachment trauma predisposes individuals to adult dissociation through three interplaying processes: (i) weakened integrative capacities, (ii) failure of the caregivers’ role in fostering a cohesive sense of self, and (iii) exposure to simultaneous or rapidly alternating incompatible attachment experiences (Farina & Meares, 2022). This combination leads to secondary, pathological oversegregation of mental contents and functions (Farina & Imperatori, 2024). Dissociation is not merely the result of unintegrated self-states or mental contents, which are its prerequisites (Schimmenti & Sar, 2019); it also involves their functional reorganization into enduring, parallel-distinct structures that coexist and/or operate simultaneously (Nijenhuis, 2009; Sar, 2017; Schimmenti, 2022a; Steele et al., 2022). Common psychopathological manifestations of dissociation include compartmentalization symptoms (e.g., amnesia, fugue, conversion disorders) and the simultaneous presence of highly incoherent mental states and contents (Farina & Meares, 2022).

Moreover, a caregiver embodying both safety and threat simultaneously activates at least two distinct innate motivational systems in the child − attachment and survival defense (Corrigan & Christie-Sands, 2020; Liotti, 2017). This concurrent activation of conflicting innate motivational systems toward the same caregiver creates internal incongruence and confusion, further fostering mental compartmentalization, pathological oversegregation of implicit relational traumatic memories, and potentially leading to dissociative identities (Bromberg, 2009; Gazzillo et al., 2020; Liotti, 2017; Van der Hart & Dorahy, 2009).

f) Pathogenic beliefs, dysfunctional implicit representations, and relational problems

The adaptation to attachment relationships with absent, neglectful, suffering, or severely abusive caregivers generates specific mental representations and pathogenic beliefs the usually lead to the typical relational problems affecting people with a history of attachment trauma. Indeed, one of the essential and primary tasks of attachment relationships is to develop meaning structures, which include beliefs and expectations about self, others and the relational dynamics between self and others that guide individuals toward evolutionarily determined goals and define part of their personality (Bowlby,1969/1982; Bretherton & Munholland, 2016; Gazzillo et al., 2020). It is widely documented that individuals with a history of attachment trauma develop pathogenic beliefs about the self as defective, failing, unable, bad, unworthy, dependent, irreversibly damaged, giving rise to feelings of shame, helplessness, worthlessness, powerless, and guilt (Farina & Schimmenti, 2025; Fimiani et al., 2020; Santoro et al., 2025a; Weiss, 1993). Moreover, both neglect and active abuse contribute to poor self-care, a propensity to engage in risky behaviors, and a pervasive distrust of oneself and others (Spinazzola et al., 2021). These experiences undermine the individual’s ability to maintain personal safety and develop healthy relationships, leading to long-term psychological consequences. In fact, these pathogenic beliefs contribute to the relational problems widely described as a typical trait of people exposed to attachment trauma who developed disorders such as complex PTSD and borderline personality disorders (Ford & Courtois, 2020; Liotti & Farina 2016). Experiences with primary caregivers in the context of attachment trauma result in the development of highly dysfunctional forms of implicit relational knowing (Stern et al., 1998), characterized by expectations that the attachment figure will be unavailable or will respond negatively to requests for help and comfort. This includes expectations of poor sensitivity, unresponsive or dysregulated reactions, and behaviors that are frightened, frightening, inconsistent, or otherwise inadequate (Fimiani et al., 2020; Fonagy et al., 2023; Gazzillo et al., 2020; Liotti, 2004; Schimmenti & Caretti, 2016). It is challenging to encapsulate the clinical and empirical evidence demonstrating how the pathogenic beliefs commonly associated with attachment trauma undermine the effectiveness of therapeutic treatments. However, it is easy to understand the difficulty in treating a patient who harbors a pathological sense of helplessness, a deep-seated sense of unworthiness leading to chronic shame (Schimmenti, 2012, 2022b), or an overwhelming sense of responsibility that manifests as survivor guilt (Fimiani et al., 2020; Gazzillo et al., 2020).

These negative beliefs often foster profound distrust, not only toward the primary caregiver but also toward subsequent meaningful relationships, including the therapeutic alliance. The pathogenic beliefs and dysfunctional interpersonal patterns that arise from attachment trauma contribute significantly to the patient’s suffering and relational difficulties, and they represent some of the most formidable barriers to successful psychotherapy. In severe cases, the impact of attachment trauma can culminate in a profound “attachment phobia” that drastically impairs the individual’s capacity to trust and rely on the care of others (Allen, 2013; Liotti, 2017; Schimmenti, 2022a, 2022b; Schimmenti & Caretti, 2016; Steele et al., 2001).

There is evidence that the child, after the age of three, in an attempt to overcome the traumatic state of “fright without solution” and attachment phobia, assume either caregiving (rescuer) or punitive (persecutor) attitudes toward their caregivers (Lyons-Ruth & Jacobvitz, 2008; Liotti, 2004). The bond with a vulnerable and helpless parent can disrupt the natural attachment dynamic, leading the child to assume an early caregiving role toward the parent, a pattern known as the controlling-caregiving strategy (Bowlby, 1988; Lyons-Ruth & Jacobvitz, 2008). In other cases, children exposed to vulnerable caregivers may adopt a more dominant and aggressive stance, seeking control through competitive and punitive behaviors toward the caregiver, which is referred to as the controlling-punishing strategy (Lyons-Ruth & Jacobvitz, 2008). Liotti (2004) further suggested that the multiple and contradictory attachment experiences implied in attachment trauma can lead to the simultaneous or rapidly alternating activation of representations of the self and attachment figure, corresponding to the three roles of the dramatic triangle: persecutor, rescuer, and victim. Within this framework, parents may be seen as persecutors when they are abusive, with the child adopting the role of the victim. However, this perception can quickly shift or coexist with another, in which the parents, due to their vulnerability or fearfulness, are perceived as the victims. In such scenarios, children may either view themselves as the persecutor − internalizing blame for the parents’ distress − or as the rescuer, feeling an urgent need to protect and save the suffering parents

Such pathological relational dynamics constitute one of the most relevant problems in the treatment of patients with attachment trauma as they hinder the therapeutic relationship and alliance (Liotti, 2017). For this reason, many clinicians suggest activating as little as possible the attachment motivational system with patients with histories of attachment trauma, at least at the beginning of the treatment, and to shift the axis of the therapeutic relationship to a more cooperative setting in order not to trigger dysfunctional attachment-related internal working models (Farina et al., 2023; Monticelli et al., 2025). Given that these patients may have developed maladaptive patterns in their relationships, minimizing the activation of dysfunctional attachment dynamics in therapy could prevent the reactivation of harmful patterns such as extreme dependency, fear, or mistrust, thereby reducing the risk of retraumatization. Also, by shifting the therapeutic relationship to a more cooperative setting, this approach emphasizes equality and partnership between the therapist and the patient, which might be especially beneficial and empowering for those who have experienced controlling or abusive relationships in the past. Also, patients with attachment trauma often come with complex developmental histories that can be easily triggered in emotionally charged therapy. A more neutral, cooperative approach may prevent the emotional overwhelm that could lead to dissociation or withdrawal from therapy, thereby supporting a more stable therapeutic process (Farina et al., 2025). However, this approach should not imply an emotional distancing toward the patient nor a lack of benevolence him or her: the opportunity for attachment repair should not be overlooked (Schimmenti, 2022a, 2022b). By dismissing the attachment dynamics, the therapeutic relationship might remain superficial, limiting the depth of the therapeutic work and resulting in missed opportunities for deeper emotional processing and integration.

The therapeutic alliance is a crucial element in successful therapy: thus, a paradox is that avoiding the reactivation of dysfunctional attachment patterns is critical, but at the same time the potential for attachment repair should always be considered. Theoretical hypotheses supported by empirical evidence suggest that to overcome the difficulties in the therapeutic relationship brought about by AT, it might be useful to employ treatments administered by different clinicians who integrate their work each other (Multiple Settings Integrated Treatments; Liotti et al., 2008): for example, individual psychotherapy and drug prescriptions, or individual and group psychotherapy in which different clinicians work in a coordinated manner (Farina & Liotti, 2005).

g) Compensatory mechanisms and maladaptive coping strategies

Attachment trauma creates an enduring sense of threat. In response to this overwhelming internal distress, individuals often adopt compensatory self-soothing strategies that function as forms of experiential avoidance. Although these strategies may initially function as adaptive mechanisms for alleviating overwhelming affect, over time they develop into maladaptive and all-encompassing coping patterns that intensify dissociation and further disrupt self-cohesion. These dysfunctional compensatory behaviors − such as addictive behaviors and non-suicidal self-injury − testifies of the maladaptive self-regulation strategies deriving from attachment trauma.

In this context, addictive behaviors − including both substance abuse and behavioral addictions − can be understood as external regulators that initially serve as protective measures to alleviate dysregulated affect. The compulsive engagement in these behaviors offers an illusory sense of mastery and control over dysregulated internal states, yet it simultaneously stabilizes the lack of integration between these states, contributing to persistent self-discontinuity (Santoro et al., 2025b). Schimmenti et al. (2022) provide compelling evidence that, in the aftermath of attachment disruptions, patients may gravitate toward addictive behaviors. They found that individuals who experienced attachment trauma were more likely to engage in substance abuse, with dissociation influencing their substance preferences. Specifically, physical and emotional abuse, in interaction with dissociation, predicted the use of sedatives, whereas sexual abuse was associated with substances inducing both excitatory and perturbative effects. Notably, childhood neglect emerged as a central predictor of substance use and its severity, reinforcing the role of early caregiving failures in later maladaptive coping.

In clinical practice, this translates into a scenario where self-soothing through addiction is not merely a symptom but a maladaptive attempt to manage dysregulated affect that sustains the lack of internal cohesion and integration (Costanzo et al., 2023). When patients engage in addictive behaviors, they may initially experience transient relief − a sense of temporary mastery over distressing internal states. However, over time, such reliance reinforces the dissociative mechanisms that further fragment the self, ultimately deepening the clinical picture (Schimmenti et al., 2025).

A similar process is also observed in non-suicidal self-injury. Bifulco and colleagues (2014) have shown that deliberate self-harm in youth is intricately linked to poor parental care, particularly neglect and role reversal. Their findings highlight that dysfunctional family dynamics and early maltreatment increase the propensity for self-injury as a maladaptive coping strategy. Accordingly, individuals from neglectful home environments, where they are forced into premature caregiving roles without parental support, struggle to develop effective affect-regulation strategies and, lacking a parental model for stress management, they may resort to self-injury as a means of tension relief and emotional escape. In the same vein, a longitudinal study by Yates et al. (2008) showed a strong association between attachment trauma and self-injurious behaviors, with dissociation emerging as a key mediating factor. The study also highlighted the role of social influences, such as peer modeling, in the initiation of self-injurious behaviors, while reinforcement mechanisms, such as tension release, contribute to their maintenance. However, among recurrent injurers − who typically begin engaging in self-injury at an earlier age and persist for longer durations than intermittent injurers − the primary motivation appears to be the regulation of intrapersonal distress. Another study by Gander and colleagues (2021) on a sample of adolescent inpatients with psychiatric disorders showed a higher prevalence of non-suicidal self-injury disorder, especially among females and patients with mood disorders. Notably, many of these self-injurious patients were classified as having an unresolved attachment status, with in-depth analysis of attachment narratives indicating that these adolescents exhibited more severe attachment trauma, characterized by themes of abuse, abandonment, and helplessness: they struggled to seek safety or regulate distress within relationships, instead experiencing overwhelming emotional breakdowns.

Collectively, these studies seem to reveal that attachment trauma primes individuals to rely on external behaviors − such as addictive behaviors and self-injury − to manage unbearable affect. While these compensatory strategies apparently offer temporary relief, among people with attachment trauma they ultimately perpetuate a cycle of self-fragmentation, impeding the recognition and integration of traumatic experiences.

h) Mentalization impairments and epistemic mistrust

Recent research has elucidated that while family, peer, sociocultural, and neurobiological factors all contribute to the development of mentalization − defined as the ability to understand oneself and others in terms of thoughts, feelings, desires, and motivations (Luyten et al., 2020) − the dyadic nature of primary attachment relationships remains the most crucial factor in either fostering or impeding these abilities. Attachment trauma often leads to significant alterations in mentalizing abilities. These alterations can manifest either as trait deficits or as state-dependent impairments (Farina & Meares, 2022; Fonagy & Target, 1997; Schimmenti & Caretti, 2016). Furthermore, research indicates that optimal mentalizing abilities in caregivers can mitigate the adverse effects of traumatic childhood experiences. Conversely, inadequate mentalization in caregivers exacerbate the impact of attachment trauma (Fonagy et al., 2023). Indeed, there is ample evidence not only that attachment trauma results in alterations in mentalization, but also that these alterations are a mediating factor between attachment and psychopathological severity (Pedone et al., 2025; De Rossi et al., 2024; Santoro et al., 2025c).

As Huang and colleagues (2020) articulated, “Attachment and mentalizing may interact in a complex causal way, in which early experiences of maltreatment lead to disruptions of the attachment system, which in turn causes mentalizing failure when the attachment system is activated. This vulnerable mentalizing triggers cascades of arousal, which then undermine mentalizing even further...” (pp. 55-56). This interaction underscores the dynamic interplay between attachment disruptions and mentalizing failures. It is essential to recognize here that mentalizing abilities, being high-level mental functions, are supported by integrative capacities. These capacities can be compromised by the arousal and emotional dysregulation triggered by implicit relational memories of traumatic attachment (Cavallo et al., 2025). Consequently, activation of the attachment system in individuals with attachment trauma can lead not only to emotional dysregulation but also to a significant failure in mentalizing abilities (Farina & Meares, 2022).

Failures in mentalizing are often associated with epistemic mistrust. Experiences in primary attachment relationships among individuals who have suffered from attachment trauma often severely impair their ability to form trusting and caring relationships. Such experiences undermine epistemic trust − the confidence in others as reliable sources of knowledge and support − in both primary caregivers and subsequent figures, including therapeutic relationships (Allen, 2013; Fonagy et al., 2023). Moreover, exposure to dysfunctional and contradictory attachment experiences can lead to “epistemic freezing”, a cognitive rigidity where the individual struggles to interpret others' intentions flexibly. This rigidity is thought to serve as a defense mechanism against the confusion and distress caused by the inconsistent and traumatic attachment experiences (Luyten et al., 2020). Epistemic mistrust, therefore, results in significant challenges in perceiving others as trustworthy and capable of facilitating meaningful change in pathogenic beliefs. This lack of trust impairs the effectiveness of psychotherapy, as patients may find it difficult to engage fully with therapeutic processes or to accept therapeutic interventions aimed at modifying maladaptive beliefs (Allen, 2013; Brüne et al., 2016; Fonagy et al., 2023). Moreover, as Fonagy and colleagues (2025) point out, complex collaborative actions such as psychotherapy require the ability to “think together” in a “we-mode” (i.e. the ability to understand both one's own perspective and that of one's partner when collaborating) and a unique set of cognitive processes guaranteed by shared and reciprocal epistemic trust. Thus, epistemic trust is both the result and product of cooperation and mentalization in psychotherapy. Like mentalization, changes in epistemic trust are not only related to the presence of psychopathology in general but mediate the onset of psychopathology in correlation with attachment trauma.

Research suggests that within therapeutic settings, activation of the attachment system can markedly diminish mentalizing abilities, whereas a cooperative therapeutic relationship tends to preserve these functions (Farina et al., 2023). This evidence supports the recommendation to shift the therapeutic relationship to a more cooperative framework to avoid triggering dysfunctional attachment patterns associated with traumatic experiences, thereby safeguarding the critical mentalization skills and epistemic trust necessary for effective psychotherapy.

Transdiagnostic relevance and clinical reasoning for attachment trauma

As mentioned in the introduction, a growing body of scientific evidence indicates that a history of attachment trauma is linked to more severe clinical presentations and treatment resistance, regardless of the specific diagnosis. For this reason, the presence of attachment trauma suggests some changes in clinical reasoning and therapeutic approach. The first change is to consider the presence of attachment trauma even in the absence of direct evidence. We have already discussed that the challenge in obtaining direct evidence of inadequate caregiving from patients necessitates to infer the presence of attachment trauma in the patient’s history from the dimensional characterization of psychopathological manifestations. Accordingly, the clinician who has to deal with the consequences of attachment trauma should move her or his clinical reasoning on three levels: a) recognize and examine the typical elements of attachment trauma among the patient's psychopathological manifestations (level of psychopathology); b) attribute them to the pathogenetic processes activated by attachment trauma (level of pathogenetic processes); and c) consider how these processes may interfere with treatment (level of therapeutic difficulties). In this way, and regardless of the patient's presenting categorical diagnosis, the clinician can deal more effectively with the consequences of attachment trauma.

In the preceding paragraphs, we outlined at least seven pathogenetic processes and related psychopathological dimensions that can manifest across all psychiatric disorders. We also mentioned how each pathogenic process can negatively interfere with therapy, regardless of the patient's diagnosis and the type of treatment used. These dimensions are often intertwined, exacerbating symptoms and further complicating treatment.

A clinical vignette

A comprehensive description of every potential clinical manifestation of attachment trauma across various psychiatric disorders would be excessively lengthy and exceed the scope of this article. Therefore, we provide a concise illustration of how these pathogenic processes may interact and contribute to poor treatment outcomes through a brief clinical vignette. To safeguard confidentiality, the patient’s name and specific details have been omitted.

Anna was 38 years old, with a solid career and a wedding on the horizon. A woman who, from the outside, seemed to have arranged the pieces of her life with precision, like a carefully set dinner table − elegant, functional, without a single misplaced fork. And yet, something trembled beneath the surface. She had come to therapy for an anxiety that clung to her skin like damp fabric, and a sadness that sat in the hollow of her chest, as if someone had left a door open inside her, letting the wind blow through.

At first, her childhood seemed distant, an old book whose pages had stuck together. She said she remembered little, though she was certain it had been normal. Still, she mentioned a mother who had shaped her with strict hands, and a father whose presence was more of an outline than a figure.

But her struggles were not just with anxiety and depression. In her most intimate relationships − whether with her fiancé or her parents − something would unravel. In those moments, she lost the thread, unable to decipher her own thoughts, let alone those of others. Emotion surged through her like a sudden storm, uncontrollable, violent. Anger would take hold of her before she could even name it. She had tried medications, but they only added another layer of distress: benign side effects, the doctors had assured her, but to her, they felt like an alarm bell ringing in her body. Therapy, too, had been a string of false starts. Each time, she would begin with hope, then find herself trapped in the same maze, until eventually, the walls closed in. She would leave, convinced she was beyond help.

Then came with another attempt − cognitive behavioral therapy. At first, it was different. The therapist's presence was solid, reassuring. Together, they examined the tangled knots of her thoughts, tracing the patterns that led her into suffering. This gave her a sense of understanding, a fragile but promising foothold. She began to trust. And when the therapist, with gentle confidence, invited her to face her fears − to step, little by little, into the world − Anna followed.

But something in those moments of exposure broke. Though she felt safe in the therapist’s office, outside, the air turned electric. Her pulse quickened, her body tensed, a shadow of something unnameable crept in. Fear swelled, vast and suffocating, swallowing her thoughts. She lost the ability to see herself clearly. Other people became opaque, their intentions unreadable, potentially cruel. The fear fed itself in a vicious loop − heightened arousal blurred her ability to think, which in turn deepened her sense of vulnerability. Shame coiled around her. She was wrong. She was small. She was nothing.

Sometimes, the world itself seemed to slip away, a film over reality that left her disconnected, floating just outside of herself. And that was terrifying. The aftermath was worse. She would walk away from those experiences hollowed out, convinced of her failure, burdened by a guilt that had no edges, only weight. A voice within her whispered that she would always be like this: powerless, worthless.

And then, as it always did, the pattern repeated itself within the walls of the therapy room. The therapist, who had once been a source of safety, became something else − someone who, while offering care, also exposed her to suffering, pushed her towards humiliation. It was too much. She left.

It was only later, in another therapy, that the memory surfaced. The unspoken thread that had woven its way through her life. The same feeling, the same helplessness. And there, in the heart of it, was her mother − demanding, critical, watching over her schoolwork with cold precision, exposing her, time and again, to failures and humiliations that burned, until she learned to detach, to step out of herself, to survive in the only way she knew how.

The case of Anna illustrates the profound impact of attachment trauma on multiple psychological domains, shaping her experiences, symptoms, and responses to therapy. Anna experiences significant dysregulation in her autonomic nervous system, particularly in response to interpersonal stress. During social exposure, her arousal levels increase rapidly, leading to a felt sense of threat and a loss of emotional control. This heightened physiological response reinforces her perception of danger, impairing her ability to think clearly and regulate herself. The chronic activation of her threat response system exacerbates her struggles with fear and emotional instability. When faced with perceived relational or social threats, Anna’s ability to maintain an integrated sense of self collapses. She loses the capacity to mentalize effectively, becomes overwhelmed by emotions, and shifts into rigid, maladaptive patterns of response. The combination of high arousal, impaired mentalizing, and emotional dysregulation leads to a fragmentation of her psychological experience, echoing past trauma in the relationship with her mother where she likely felt similarly overwhelmed and unable to make sense of her experiences. Anna's struggles with emotional regulation manifest in sudden outbursts of anger and intense distress in intimate relationships. She oscillates between emotional flooding and numbness, unable to modulate her affective responses adaptively. Her difficulty in tolerating distress also explains her inability to persist in previous therapies − when faced with the inevitable discomfort of treatment, she becomes overwhelmed, loses hope, and disengages. Additionally, her reliance on medication and avoidance of deeper therapeutic work reflects a maladaptive attempt to manage discomfort without addressing underlying issues. At times of extreme distress, Anna describes feeling detached from both herself and the external world, a classic dissociative response to overwhelming affect. These episodes likely represent a survival strategy formed in childhood − when faced with inescapable distress (i.e., her mother's criticism and humiliations), her psyche protected itself by creating a mental distance. This same response emerges in social situations and in therapy, further impairing her ability to engage meaningfully with her environment. Anna's history is thus marked by deep-seated difficulties in trusting and connecting with others, a mistrust rooted in the relationship with her mother: while she initially experiences her therapist as supportive and safe, this perception shifts dramatically when therapy challenges her. She begins to see the therapist as both caring and threatening, mirroring the conflicting experience she had with her mother. This dynamic leads her to withdraw, cutting off the therapeutic relationship just as she had disengaged from other significant relationships in her life.

Furthermore, Anna operates within a cognitive framework in which she perceives herself as fundamentally incapable, powerless, and destined to fail. Each unsuccessful attempt at therapy reinforces her belief that she is beyond help. This sense of helplessness is particularly exacerbated when she encounters distressing experiences in therapy that she cannot regulate, reinforcing the conviction that she lacks agency and control over her own emotional world. Finally, one of the most crucial elements in Anna’s struggles is her epistemic mistrust − her difficulty in accepting new, potentially helpful information about herself from others, particularly from authority figures like therapists. Initially, she can engage in mentalizing − understanding her own thoughts and emotions and those of her therapist − but under stress, this ability collapses. When overwhelmed, she reverts to seeing others as unpredictable or even hostile, reinforcing her distrust and leading her to disengage from the therapeutic process. Notably, underlying much of Anna’s distress is a deep-rooted sense of shame. She perceives herself as defective, “wrong,” and unworthy, a self-concept likely shaped by her early experiences with a critical mother. Each failure − whether in social interactions or therapy − triggers this latent shame (Schimmenti, 2022b), making her feel even more exposed and unworthy, which reinforces her perception of inability to succeed in therapy as a personal failing rather than a reflection of trauma-related impairments.

As depicted in Anna’s case, relational difficulties, maladaptive beliefs about helplessness or powerlessness, challenges in emotional and behavioral regulation, limited ability to articulate one’s feelings and symptoms to the clinician, and a lack of trust in the therapist or the therapeutic process all negatively impact the therapeutic relationship. These factors hinder the therapeutic alliance and further compromise the effectiveness of psychotherapeutic strategies and techniques (Farina et al., 2025).

Therapeutic implications

We already specified that attachment trauma is not a clinical diagnosis, but a condition that results in a specific psychopathological vulnerability that spreads across all psychiatric disorders. Therefore, there is not and cannot be a specific treatment protocol or a therapeutic model for attachment trauma. On the contrary, the optimal strategy would involve adapting treatments for the different pathogenetic processes described in the preceding paragraphs by tailoring them in an individualized manner to the single patient.

Therapeutic approaches and strategies to addressing the clinical consequences of attachment trauma arise from diverse modalities and theoretical frameworks, but they commonly share several key therapeutic elements designed to address the pathogenic processes of attachment trauma. These shared elements include: (a) the establishment of a safe therapeutic relationship that provides a corrective relational experience to counter interpersonal traumatic patterns; (b) creating a therapeutic relationship based on peer cooperation to minimize the effects of activating the attachment system and its traumatic implicit memories (IWMs); (c) the ongoing monitoring of the therapeutic alliance and its repair in case of impasse; (d) the use of techniques and strategies for the regulation of vegetative arousal and its stabilization; (e) the regulation of emotions and impulses; (f) work on negative pathogenic beliefs about self and others, along with the negative emotions associated with them; (g) the management of detachment symptoms; (h) the use of strategies and techniques for integrating the dissociated self-states and parts of personality; (i) the enhancement of mentalization strategies; (j) promoting epistemic trust; and (k) the processing of both implicit and explicit traumatic memories. In the subsections devoted to each of the pathogenetic processes involved in attachment trauma, specific therapeutic strategies and tools have been briefly outlined. We have summarized them in table 1 (a more detailed description of each therapeutic element would be beyond the scope of this article, and we refer to the cited publications for their further examination).

Table 1.

Core clinical components in attachment trauma treatment

	Establishment of a Safe Therapeutic Relationship	Regulation of Emotions and Arousal	Modification of Pathogenic Beliefs	Addressing Detachment Symptoms and Dissociated Self- States	Promotion of Mentalization and Epistemic Trust	Processing Implicit and Explicit Traumatic Memories
Conceptualization	This process serves as a corrective emotional and relational experience, offering a model of healthy and reliable interpersonal interactions.	This process enables individuals to tolerate and process distressing or dysregulated emotions without becoming emotionally overwhelmed.	This process serves to dismantle the internalized negative self-view and fosters healthier self-concept and healthier interpersonal	This process helps to avoid automatic defensive withdrawal in response to current stressors and trauma-related memories.	This process aids in developing a more coherent sense of self and better interpersonal relationships.	This process facilitates the organization of fragmented and traumatic memories into a coherent narrative, thereby diminishing their intrusive and disruptive influence on daily life.
Clinical objectives	Helping patients begin to rework and heal from maladaptive relational patterns developed in response to attachment trauma.	Learning techniques to manage intense emotional experiences and dysregulated physiological responses—such as grounding exercises and emotion regulation skills.	Identifying, challenging and reframing negative pathogenic beliefs about the self and others that are rooted in early attachment trauma.	Helping patient to reduce dissociation of self-states and symptoms of detachment and compartmentalization.	Fostering patient’s exploration of mental states and promoting epistemic trust.	Addressing implicit and explicit traumatic memories.
Expected outcomes	Facilitating the capacity for engagement in the therapeutic process and cultivating a sense of stability and support that was insufficiently experienced during early relational development.	Achieving greater emotional stability, reducing affect dysregulation, and mitigating the physiological impact of stress and trauma.	Reducing feelings of shame, worthlessness, and insecurity.	Reconnecting the fragmented aspects of self.	Enhancing the capacity for self- and other- understanding and facilitating meaningful engagement with therapeutic insights.	Supporting the processing and cognitive-emotional integration of early attachment-related experiences to diminish their adverse influence on current emotional, relational, and behavioral functioning.

Concluding remarks

The proposed clinical framework emphasizes the crucial role of early identification of attachment trauma, even in patients whose clinical diagnoses or personal histories may not overtly suggest experiences of childhood maltreatment. Indeed, the purpose of this article was to define the construct of attachment trauma and to describe its clinical consequences and therapeutic implications. Patients with a variety of psychiatric disorders and psychopathological elements of attachment trauma have often been identified as “difficult patients” or as belonging to diagnostic subcategories resistant to common treatments (Farina & Liotti, 2013). By systematically recognizing and addressing the therapeutic needs associated with attachment trauma, clinicians can more skillfully manage the complexities inherent in treating individuals who have been exposed to attachment trauma. This comprehensive approach allows interventions to be tailored to meet the unique challenges posed by these patients, thereby supporting their recovery process and improving treatment outcomes.