Attachment Theory and Reactive Attachment Disorder: Theoretical Perspectives and Treatment Implications

Journal of Child and Adolescent Psychiatric Nursing, Feb 2007 by Hardy, Lyons T

The neuropsychoanalytic perspective adds a neurobiological component to these perspectives. According to Schore (1994), the affective exchanges between infant and caregiver provide a foundation for neurological development and lead to the creation of neural networks (particularly in the right hemisphere) that will influence the infant's personality and relationships with others throughout life. Neural activity in the right hemisphere creates and maintains continuity of inner affective experience amidst external changes. This continuity is subjectively experienced as a sense of self. In addition, the right hemisphere has extensive reciprocal neural connections to the autonomic nervous system and thus regulates physical reactions to affective stimuli as well. Furthermore, the right hemisphere is dominant in the reception, interpretation, and communication of emotion, and optimal functioning in these areas would be an essential component for empathic interpersonal experiences.

Schore (2002) contends that attachment constitutes "synchronized dyadic bioenergetic transmissions" between infant and caregiver (p. 444). The caregiver's ability to modulate and process affective states and provide this structure to the infant is the most important factor in the infant's early brain development. Since information processing in the brain occurs as a result of metabolic changes, intrapersonal and interpersonal experience is seen as the alteration of energy patterns within and between systems (Schore, 1994). Schore also suggests that the maintenance of homeostasis and equilibrium in infants' central and autonomic nervous systems is dependent on their reciprocal interactions with caregivers. If the relationship is disrupted, the infant's nervous system must expend large amounts of energy to maintain equilibrium independently. When this energy expenditure fails, the right brain is unable to maintain coherent neural connections and goes into a state of shock that leads to dissociation and stalls normal development. When both internal and external regulatory systems fail, a sense of helplessness (inability to self-maintain) and hopelessness (loss of predictable outer structure) could result.

Indeed, Fonagy et al. (1996) found significant associations between affective disorders and unresolved attachment status. In addition, Maunder and Hunter (2001) conducted a literature review of studies examining attachment status and physical health and concluded that there is an association between attachment insecurity and physical illness. Potential etiological factors include increased susceptibility to stress, increased reliance on external affect regulation, and increased help-seeking behaviors. Other evidence suggests that a defining characteristic of personality disorder is an inconsistent and unstable sense of self that is reflected in difficulties maintaining functional and socially appropriate interpersonal relationships. One meta-analysis of 13 studies found that attachment insecurity was strongly associated with borderline personality disorder (Agrawal, Gunderson, Holmes, & Lyons-Ruth, 2004). Brennan and Shaver (1998) also found attachment style to be correlated with personality-disorder measures. These data add support to Schore's claim that attachment problems lead to insufficient development in the right hemisphere resulting in dysregulation of self-perception and altered autonomic response to external events.