Exposure to interpersonal trauma, attachment insecurity,
and depression severity
J. Christopher Fowlera,b,n, Jon G. Allena,b, John M. Oldhama,b, B. Christopher Frueha,b,c
aThe Menninger 12301 Main Street, Houston, TX 77035, USA
bBaylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA
cUniversity of Hawaii, Department of Psychology, 200 West Kawili Street, Hilo, HI 96720, USA
a r t i c l e i n f o
Received 20 December 2012
Accepted 30 January 2013
Available online 16 March 2013
a b s t r a c t
Background: Exposure to traumatic events is a nonspecific risk factor for psychiatric symptoms
including depression. The trauma–depression link finds support in numerous studies; however,
explanatory mechanisms linking past trauma to current depressive symptoms are poorly understood.
This study examines the role that attachment insecurity plays in mediating the relationship between
prior exposure to trauma and current expression of depression severity.
Methods: Past trauma and attachment anxiety and avoidance were assessed at baseline in a large
cohort (N¼705) of adults admitted to a specialized adult psychiatric hospital with typical lengths of
stay ranging from 6 to 8 weeks. Depression severity was assessed at day 14 of treatment using the Beck
Results: Interpersonal trauma (e.g., assaults, abuse) was correlated with depression severity, whereas
exposure to impersonal trauma (e.g., natural disasters, accidents) was not. Adult attachment partially
mediated the relationship between past interpersonal trauma and depression severity at day 14 among
Limitations: Measure of trauma exposure did not systematically differentiate the age of exposure or
relationship to the perpetrator. Individuals scoring high on the self-report attachment measure may be
prone to over-report interpersonal traumas.
Conclusions: Treatment of depression in traumatized patients should include an assessment of
attachment insecurity and may be fruitful target for intervention.
& 2013 Elsevier B.V. All rights reserved.
Extensive research has established that childhood and adult
stress induced by exposure to traumatic events can lead to a
variety of negative health outcomes such as posttraumatic stress
disorder, substance abuse, suicide attempts, and depressive dis-
orders (Brewin, 2003; Brodsky et al., 1997; Caspi et al., 2003;
Kingree et al., 1999; Kendall-Tackett et al., 1993; Kendler et al.,
2000; Koenen et al., 2007; Heffernan et al., 2000). Depressive
symptoms are thoroughly intertwined with these disorders and
behaviors, and particularly so with PTSD (Elhai et al., 2011).
Furthermore, research indicates that depression is a more com-
mon outcome of trauma than PTSD (Bryant, 2010). A wide range
of events can be experienced as traumatic and, among these, it is
useful to distinguish broadly between those that are relatively
impersonal, such as natural disasters and accidents, and those
that are interpersonal, such as assaults, battering in partnerships,
and maltreatment in childhood (Allen, 2001). Interpersonal stress
is a well-documented risk factor for depression (Brown, 2010;
Brown and Harris, 1978; Hammen, 2005), and interpersonal
trauma constitutes extreme stress.
The most extensive research relating interpersonal trauma to
adulthood depression has focused on trauma in childhood attach-
ment relationships in the form of abuse and neglect (Anda et al.,
2006; Bifulco and Thomas, 2013; Brown and Harris, 1993; De
Marco, 2000; Price et al., submitted for publication; Spertus et al.,
2003). Such early trauma sets the stage for impairments in
neuroregulatory systems related to stress and affect regulation,
with profound and lasting behavioral consequences (De Bellis and
Thomas, 2003; Gutman and Nemeroff, 2002; Heim and Nemeroff,
2001; Repetti et al., 2002; Teicher, 2000) including stress toler-
ance and stress generation in later relationships (Hammen, 2005),
as well as heightened risk of exposure to interpersonal trauma in
adulthood (Cloitre et al., 1997; Widom, 1999). It is also well
established that trauma and stress result in the expression of
Contents lists available at SciVerse ScienceDirect
journal homepage: www.elsevier.com/locate/jad
Journal of Affective Disorders
0165-0327/$-see front matter & 2013 Elsevier B.V. All rights reserved.
nCorresponding author at: The Menninger Clinic, 12301 Main Street, Houston,
TX 77035, USA. Tel.: þ1 713 2755508.
E-mail address: email@example.com (J.C. Fowler).
Journal of Affective Disorders 149 (2013) 313–318
depression in less than 50% of cases even when multiple traumas
and stresses are present (Anda et al., 2006), indicating that
individual characteristic including psychological processes may
mediate the impact of trauma on the expression of depression.
Attachment theory and research is especially germane to the
study of the relation between interpersonal trauma and depres-
sion (Bowlby, 1980) because attachment theory provides a
powerful model for understanding the interplay among mental
representations, affect regulation, patterns of interpersonal beha-
vior, and psychopathology. A fundamental tenet of attachment
theory posits that the quality of child–caregiver relationships
impacts the development of attachment security. Thus, early
adverse events are assumed to have a negative impact on adult
attachment. For example, in large community samples, past
sexual abuse is correlated with insecure attachment patterns in
adulthood (Alexander, 1993; Styron and Janoff-Bulman, 1997).
Yet continuity and discontinuity in the quality of attachment
relationships over the entire course of development influence
stability and change in attachment security (Bifulco and Thomas,
2013; Mikulincer and Shaver, 2007).
In turn, attachment security is hypothesized to affect the
quality of relationships, psychological functioning, and illness in
an ongoing fashion. Longitudinal studies of early attachment
patterns attest to the beneficial effects of secure attachment in
affect regulation, distress tolerance, and the capacity to develop
and maintain friendships (Sroufe et al., 2005). Secure attachment
status in adolescence appears to be a protective factor against the
development of personality disorders (Nakash-Eisikovits et al.,
2002; Westen et al., 2006). Secure attachment in adulthood is
related to greater capacity to regulate affect, self-esteem, and
stress reactivity (Mikulincer and Shaver, 2004, 2007).
In contrast, insecure attachment, evident in attachment anxi-
ety and avoidance, is associated with greater levels of psycho-
pathology following stressful life events (e.g., Davila et al., 1996),
negatively impactsthe ability
(Mikulincer and Shaver, 2004, 2007; Shaver and Clark, 1994),
limits the utility of internal working models to down-regulate
negative affect (Mikulincer and Shaver, 2008; Selcuk et al., 2012),
and confers risk for major physical illness (Hazan and Shaver,
1990; McWilliams and Bailey, 2010). Among diabetic patients,
attachment insecurity is linked to greater dissatisfaction and
difficulty forming collaborative relationships with healthcare
providers (Ciechanowski and Katon, 2006), poorer medication
compliance (Ciechanowski et al., 2004), and higher mortality
rates in a 5-year follow-up (Ciechanowski et al., 2010).
The extent to which attachment insecurity mediates the
vulnerability to depression in the wake of trauma merits
systematic investigation, in part because attachment insecurity
is liable to compromise treatment for depression. A small
prospective study (Conradi and de Jonge, 2009) revealed that
patients characterizedby extreme
evidenced a greater number of prior depressive episodes, sig-
nificantly worse depression course, greater number of residual
symptoms, and worse social functioning compared to securely
attached individuals. A second longitudinal study demonstrated
that attachment insecurity partially mediates the relationship
between past trauma and the emergence and recurrence of
depressive symptoms (Bifulco et al., 2006); however, the find-
ings were based on a small community sample of females, and
the 3-year follow-up did not account for intervening stressful
life events,limitingtheir generalizability.
(Williams and Riskind, 2004) investigated the mechanisms for
vulnerability to recurrent depressive episodes and found that
cognitive vulnerabilities to depression were partially mediated
by attachment insecurity, suggesting that attachment insecurity
may represent an antecedent to depressogenic cognitions.
The study used undergraduate students with depression scores
ranging from none to mild, which significantly limits the gen-
eralizability to clinical samples.
The current study tests a mediation model using a large
sample of adult psychiatric inpatients with significant levels of
trauma exposure, attachment insecurity, high co-morbidity of
psychiatric illness, and moderate to severe depression. Hence this
population is ideal for examining the extent to which attachment
insecurity mediates the relation between interpersonal trauma
and depression. Given the intensive treatment exposure and rapid
improvement in depression severity found in a larger representa-
tive sample of inpatients over the course of 6 weeks of treatment
(Clapp et al., in press) the 14 day interval allows for a test of
mediation while constraining the impact of treatment dose and
intervening stressful life events. Three hypotheses were tested
prior to testing the primary hypothesis of mediation: 1. Imper-
sonal traumas (i.e., exposure to combat, natural disasters, life-
threatening accidents and witnessing violence) will not be
correlated with current attachment insecurity, because such
traumas will not activate attachment anxiety or avoidance; 2.
As a consequence, attachment insecurity will not mediate the
relationship between impersonal trauma and depression sever-
ity; 3. Interpersonal trauma will be correlated with attachment
insecurity and depression severity. Confirmation of the hypoth-
eses 3 sets the stage for testing the hypothesis that attachment
insecurity mediates the relationship between past interperso-
nal trauma and subsequent depression.
Participants were 705 individuals admitted to a specialized
psychiatric hospital between November 2009 and January 2011.
Gender distribution was comparable: 362 were women (51%) and
343 were men (49%). Average age was 33.9 years (SD¼14.4).
Most participants were single–never married (n¼420, 60%) or
currently married (n¼164, 23%). Participants were Caucasian
(n¼643, 91%), multiracial (n¼36, 5%), Asian (n¼8, 1%), and
African American (n¼5, 7%). Thirty-one participants (4%) identi-
fied as being of Hispanic or Latino ethnicity. A majority (62%) of
participants were not working prior to admission.
Data were collected as part of the hospital’s Adult Outcomes
Project, described in detail elsewhere (Allen et al., 2009). In brief,
all participants were assessed using established, validated mea-
sures at admission and were reassessed periodically over the
course of treatment. Assessments were conducted via a hospital-
wide web survey on laptop computers. This project was a clinical
outcomes project, conducted with all patients; thus no patients
declined participation, as it was part of their routine clinical care.
Use of the project’s data was approved by Baylor College of
Medicine’s Institutional Review Board (IRB). Baseline measures
were collected within 72 h of admission, followed by re-
administration of selected measures at 14 day intervals during
2.3.1. Trauma exposure
This questionnaire, adapted from a measure designed to screen
for trauma history in an inpatient population (Allen et al., 1999),
consists of 10 binary distinctions of past exposure to traumatic
J.C. Fowler et al. / Journal of Affective Disorders 149 (2013) 313–318
events including interpersonal violence, secondary exposure, and
natural disasters and accidents. The questionnaire was adminis-
tered at admission. The items were subjected to a factor analysis
(principle components with promax rotation and Kaiser normal-
ization) yielding an interpersonal trauma factor (Eigen value: 2.6:
26% variance) and an impersonal trauma factor (Eigen value: 1.3:
13% variance). Table 1 includes trauma items, distribution char-
acteristics, and factor loadings (Table 1).
2.3.2. Relationship Questionnaire (RQ)
The RQ (Bartholomew and Horowitz, 1991) is a prototype
measure derived by crossing two theoretical dimensions of
attachment representations: model of self (positive/negative)
and model of other (positive/negative). The measure provides
respondents with prototypical descriptions of secure, dismissing,
preoccupied, and fearful attachment patterns. Respondents select
the prototype that best describes the way they generally are in
close relationships, and they rate each prototype on a 7-point
scale regarding the extent to which each description corresponds
to their general relationship style. The questionnaire was admi-
nistered at admission. A negative model of self is associated
with attachment-related anxiety based on doubts that the self
is worthy of attention and affection, creating worries that
relationship partners will not be available in times of need.
Negative model of other is associated with attachment-related
avoidance and is rooted in a person’s distrust of relationship
partners’ goodwill, which causes him or her to maintain beha-
vioral and emotional independence and distance from others.
Individuals who score in a positive range for model of self and
model of other are categorized as having a prototypic secure
2.3.3. Beck Depression Inventory-II (BDI-II)
The BDI-II (Beck et al., 1996b) is a 21-item self-report measure
of depression symptoms, modified from the original BDI to be
more consistent with DSM-IV major depressive disorder item
content. Prior research shows that the BDI-II demonstrates
adequate test–retest reliability (r¼.93), internal consistency
(alphas of .91–.93 with clinical and non-clinical samples),
and convergent/discriminant construct validity with external
measures of depression and anxiety (Beck et al., 1996a, 1996b).
The BDI-II is administered at admission and at 14 day intervals. The
depression severity data for this study are based on the assessment
14 days after admission in order to meet the requirement for
mediation analyses that there must be temporal distance between
the assessment of the independent and dependent variables. The 2-
week point provides necessary temporal separation while being of
sufficiently brief duration as to preclude the influence of a range of
other potential mediating variables.
2.3.4. Research diagnoses
Psychiatric diagnoses (American Psychiatric Association, 2000)
were available for 382 (54%) of the study sample utilizing the
Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I:
First et al., 2002) and Axis II disorders (SCID II: First et al., 1997).
Prior to initiating interviews, master’s level researchers reviewed,
1. Psychiatric evaluation including past psychiatric history, 2.
Collateral information from family, 3. Psychosocial assessment, 4.
Nursing staff assessment. In addition, interviewers consulted with
the attending psychiatrist at any point in the process to obtain
additional information to aid in diagnostic assessment. This
process combined the ecologically valid longitudinal evaluation
of all available data diagnostic approach (LEAD: Pilkonis et al.,
1991) with the rigorous diagnostic interviews of SCID I and SCID
II. DSM-IV-TR Axis I research diagnosis interviews and coding
were conducted according to procedures for inpatient samples
(First et al., 2002). Following Axis I interviews, subjects were
administered the SCID-II Personality Questionnaire, then the SCID
II interview (First et al., 1997).
2.3.5. Data analysis
Analyses were conducted using SPSS for windows, version 19.1
(IBM). Zero-order correlation coefficients were calculated for
variables of interest. Following procedures for mediation (Baron
and Kenny, 1986; Frazier et al., 2004) a series of regression
analyses was performed: to determine, first, if interpersonal
trauma relates to attachment anxiety and attachment avoidance;
second, if interpersonal trauma relates to depression severity at
day 14 of treatment; and third, if interpersonal trauma relates
to depression severity, controlling for attachment anxiety and
attachment avoidance. Mediation is indicated when the inde-
pendent variable is significantly related to the mediator, the
independent variable is significantly related to the dependent
variable, and the effect of the independent variable on the
dependent variable is weakened when the proposed mediator
is controlled (Baron and Kenny, 1986). Mediation was con-
firmed using the Sobel test (Soper, 2012). Taking into account
multiple comparisons, p-values less than .01 were considered
Descriptive statistics (Table 2) indicate that patients experi-
enced a high burden of illness with an average of 3.7 (SD¼1.3)
Axis I and Axis II disorders along with moderate to severe level of
depression at admission (mean BDI-II¼25.7; SD¼12.5).The rates
of trauma exposure were high: 419 out of 705 inpatients (59%)
experienced at least one prior lifetime traumatic experience. Of
those, 369 (52%) experienced at least one interpersonal trauma,
and 173 (25%) were exposed to at least one impersonal trauma.
On average, patients report high levels of attachment anxiety as
well as attachment avoidance. Computation of the attachment
status indicates that 536 (76%) patients are categorized as
insecurely attached (attachment anxiety and/or attachment
avoidance scores in the negative range).
Zero-order correlations are reported in Table 3. Interpersonal
trauma was significantly correlated with attachment anxiety and
Trauma variables and factor loadings (N¼705).
Trauma variableFreq % Interpersonal
Physical threat, assault, attack or
Sexual assault (rape or attempted
Physical torture by someone
Sexual molestation by someone
Terrorized, tormented, stalked, or
23233 .64 .11
Witness to killing, maiming, or
Accident that was life-threatening
Natural disaster that was life-
Military combat or a war zone
Accidentally causing serious injury
9914 .10 .48
nPromax rotation with Kaiser normalization.
J.C. Fowler et al. / Journal of Affective Disorders 149 (2013) 313–318
avoidance as well as depression severity at 14 days of treatment;
all effect sizes were small. Attachment anxiety and attachment
avoidance correlated with depression severity with moderate
effect sizes. These results indicate that assessment of potential
mediation is indicated. Exposure to impersonal trauma was not
correlated with attachment anxiety, attachment avoidance, or
depression and was therefore dropped from further analyses.
Regression analyses and the Sobel test were used to determine
if attachment status mediated the relationships between trauma
and depression severity (Table 4). After controlling for attachment
status, the magnitude of initial significant relationships between
trauma and depression severity decreased, suggestive of partial
mediation. Sobel’s tests of the indirect effects of trauma on
severity of depression via attachment anxiety and avoidance are
significant (Z¼2.44, p¼.01), converging with the regression
analyses to indicate partial attachment mediation of the relation
between interpersonal trauma and depression.
Bowlby’s seminal work (Bowlby, 1973, 1980, 1982) set the
stage for longitudinal research demonstrating how trauma in
early attachment relationships initiates a developmental cascade
in which insecure attachment and psychopathology become
intertwined (Sroufe et al., 2005). More broadly, the results of this
study support the thesis that exposure to interpersonal traumas
impact attachment status, whereas impersonal traumas bear no
discernible relationship to attachment in this inpatient sample.
In this large-scale inpatient study prevalence rates for trauma
exposure are somewhat lower than those found in community
samples with severe mental illness (Cusack et al., 2004; Subica
et al., 2012), which may reflect an instrument artifact of the
trauma measures used. The prevalence rate of 59% trauma
exposure is equivalent to that reported in epidemiological studies
of trauma and PTSD (Kessler et al., 1995). The substantial
prevalence of trauma histories, coupled with the moderate-to-
severe level of depression at baseline and high rate of attachment
insecurity provides a good sample from which to test for mediation.
The small effect size of the correlation between interpersonal
trauma and depression severity indicates that interpersonal trauma
alone does not predict later depression severity. The medium effect
size of the correlation between attachment insecurity and depres-
sion severity indicates that attachment status also has a limited role
in depression severity at 14 days of treatment.
The fact that exposure to impersonal trauma was completely
unrelated to depression severity and attachment status is highly
relevant to the differential impact of specific forms of traumatic
experiences on psychiatric outcomes and the complexity of the
trauma–illness relationship (Hovens et al., 2012; Huang et al.,
2012). Interpersonal traumas are related to later attachment
status, and attachment status partially mediates the relationship
to depression severity after 14 days of treatment.
These findings add to a growing body of evidence demonstrat-
ing the impact of attachment anxiety and attachment avoidance
to the expression of various forms of psychopathology. While the
evidence relating childhood trauma exposure to lifetime risk for
major mental health and physical health disorders is substantial
(Anda et al., 2006; Felitti and Anda, 2010), the mediating role of
attachment adds a level of psychological complexity to this
relationship. For example, Waldinger et al. (2006) demonstrated
that attachment partially mediates the relationship between
trauma exposure and the development of somatic illness. Among
diabetic patients, attachment insecurity is linked to greater
interpersonal distance, dissatisfaction and difficulty forming col-
laborative relationships with healthcare providers, and poorer
medication compliance (Ciechanowski et al., 2004) as well as
higher mortality rates (Ciechanowski et al., 2010).
The findings from the present study yield straightforward
implications for the treatment of depression in traumatized
patients, namely, that improving security in current attachment
relationships is a worthy goal. The importance of social support in
treating psychiatric disorders is widely recognized, but the pre-
sent findings emphasize a more specific focus on the attachment
aspects of interpersonal relationships, namely, their primary role
in regulating distress by providing a feeling of security (Sroufe
and Waters, 1977). Indeed, a compelling case has been made that
secure attachment relationships are the most efficient and potent
means of distress regulation (Coan, 2008). There may be some
Zero-order correlations and descriptive statistics.
Variable1 2345 MeanSD
1. Interpersonal trauma
2. Impersonal trauma
3. Attachment anxiety
4. Attachment avoidance
5. BDI-II at 14 daysn
Predictor variable Outcome variable
b¼ unstandardized beta coefficient, SE¼ standard error, b¼ standardized beta coefficient, t¼ t-value.
aControlling for attachment anxiety and attachment avoidance.
Descriptive statistics (N¼705).
Length of stay (days)
Total DSM-IV axis I/II
3 .31 .59
J.C. Fowler et al. / Journal of Affective Disorders 149 (2013) 313–318
distinct advantages to viewing psychotherapy alliance from the
vantage of an evolving attachment relationship in which clini-
cians attend to the quality of the alliance as a factor that can
influence short-term treatment outcomes (Fl¨ uckiger et al., 2012),
while establishing a more secure attachment relationship with a
therapist may then generalize to important others in the indivi-
dual’s life (Allen, 2012).
The current study builds upon previous work demonstrating
a mediating relationship between trauma in attachment rela-
tionships and depression severity (Bifulco et al., 2006; Williams
and Riskind, 2004). Yet a significant limitation of the measure of
trauma exposure in the present study must be acknowledged:
the items do not systematically differentiate the age of exposure
or the relationship with the perpetrator (i.e., the extent to which
the trauma occurred in the context of attachment). A second
limitation is related to the self-report measure of attachment
and the possibility that individuals scoring high on insecure
attachment may be prone to over-report interpersonal traumas.
These limitation notwithstanding, the current study includes a
number of strengths: a large sample with relatively high rates of
trauma, attachment insecurity, and a moderate-to-severe level
of depression at baseline; balanced representation of male and
female adults, allowing for greater generalizability than earlier
studies; and the selection of psychiatric inpatients with severe
mental illness, which is preferable to assessment of college
students with negligible depression severity. While an inpatient
population limits the generalizability to less severely disturbed
outpatient samples, there is a growing demand for research on
serious mental illness due to greater awareness of its prevalence,
cost, and burden (Druss and Bornemann, 2010; World Health
Role of funding source
This research was supported by grants from the Menninger Foundation and
the McNair Medical Institute. Drs. Fowler & Frueh are McNair Scholars.
Conflict of interest
There are no conflicts of interests for any authors.
Special thanks to Steve Herrera, Tina Holmes, Heather Kranz, Herman Adler,
Mike Ulanday, Allison Kalpakci, and Alison Arquero for data collection and project
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