Associations Between Childhood Trauma, Attachment, and Empathy in PTSD

Abstract

Introduction: Individuals with post-traumatic stress disorder (PTSD) may experience alterations in empathic ability, that is, lowered empathic concern (worry and care for those in need) and perspective taking (adopting another’s viewpoint), but heightened personal distress when they perceive others as distressed (discomfort witnessing others in pain). Some research suggests these alterations in empathy are related to patterns of insecure attachment that developed in early childhood. For example, some people may have difficulty separating from attachment figures due to fear of being abandoned or rejected (anxious attachment). Others may behave in overly guarded, disconnected, or dismissive ways due to an inability to depend on important attachment figures (avoidant attachment). It remains unknown exactly how distinct attachment styles are related to alterations in empathy. Given that empathy plays an important role in social functioning, understanding these relationships may help identify treatment targets to enhance quality of life and improve interpersonal relationships. Therefore, we examined the relationship between anxious and avoidant insecure attachment styles and aspects of empathic functioning in PTSD.

Methods: Participants were 88 patients with current PTSD and histories of interpersonal trauma recruited from outpatient settings at two psychiatric hospitals in the northeastern United States. Participants completed a battery of self-report measures including the Interpersonal Reactivity Index, which captures four facets of empathy: personal distress, empathic concern, perspective taking, and fantasy, the revised Experiences in Close Relationships questionnaire, which assesses attachment-related anxiety, the Childhood Trauma Questionnaire, and the PTSD Checklist for DSM-5.

Results: Linear regressions with robust standard errors revealed that after controlling for demographic variables (sex assigned at birth, race, ethnicity, age), childhood trauma severity, and PTSD symptom severity, greater avoidant attachment predicted lower empathic concern, b=-.87, t=-2.13, p=.037. Greater anxious attachment predicted higher personal distress, b=1.76, t=3.02, p=.004. Insecure attachment style did not predict perspective taking or fantasy scores. To further explore the impact of childhood trauma severity on patterns of empathy, we divided the sample into groups with minimal childhood maltreatment (n=20) and moderate to severe childhood maltreatment (n=68). Results demonstrated that these groups did not differ in levels of empathic concern. However, individuals with moderate to severe experiences of childhood maltreatment demonstrated greater personal distress as compared to those with minimal childhood maltreatment, t(86) = -1.87, p < .033.

Conclusions: These findings suggest anxious and avoidant forms of insecure attachment are related to different patterns in empathic functioning. Avoidant attachment was associated with lower empathic concern for others, whereas anxious attachment was associated with higher personal distress in difficult interpersonal interactions. Moreover, those with more severe childhood maltreatment endorsed greater personal distress in challenging interpersonal interactions. These results highlight connections between empathic ability and insecure attachment, which impact adult social functioning and mental health more broadly. Treatments targeting insecure attachment may improve social wellbeing for individuals with PTSD.

Authors: Zoe A. Bair, Cori A. Palermo, Rebecca L. Modell, Mollie C. Marr, Xi Pan, Juliann B. Purcell, Meghan E. Shanahan, Michaela B. Swee, Matthew A. Robinson, Milissa L. Kaufman, Lauren A. M. Lebois.