The Role of Attachment in Poly-Drug Use Disorder: An Overview of the Literature, Recent Findings and Clinical Implications

Abstract

Background: Substance use disorders (SUDs) represent a worldwide epidemic with extensive costs to the individual and to society. Occasionally described as an attachment disorder, they have been linked to various impairments in self-regulation and social functioning. However, while there have been significant advances in the development and validation of treatment strategies for SUD in recent years, the components of these treatment approaches have yet to be fully explored. The characteristics of polydrug use disorder (PUD) especially need to be addressed in more detail, as this diagnosis is highly common in individuals seeking treatment, while simultaneously being associated with poor treatment success. Aim and Scope: This review aims at further exploring the relevance of attachment in PUD and its treatment. To this end, this review provides a concise summary of relevant theories on the development and treatment of SUD in general, including related parameters of attachment, emotion regulation, and neuroscience. Furthermore, several studies focused specifically on PUD are described in more detail. These studies explored the connections between attachment, personality structure, primary and higher emotions (including spirituality), as well as structural and functional neural parameters in inpatients with PUD as well as in healthy controls. Most notably, the described studies highlight that insecure attachment and impairments in personality structure are present in inpatients with PUD. In addition, these characteristics are paralleled by extensive impairments in white matter integrity, especially in tracts connected to facets of emotion regulation. Conclusions: Based on our findings, we emphasize conceptualization of PUD as an Attachment Disorder, on a behavioral as well as on a neural level. Furthermore, we point out the importance of an integrated bio-psycho-social approach in this research area. Consequently, future studies might more closely focus on the influence of attachment-based interventions on emotion regulation abilities as well as a potentially related neuroplasticity. Neuroplastic changes, which are still rather unexplored, might represent important parameters for the assessment of treatment outcomes especially in long-term SUD treatment.

Attachment Style, Early Childhood Trauma, Alexithymia, and Dissociation Among Persons Addicted to Alcohol: Structural Equation Model of Dependencies

“…There is an extensive database of study results in literature which connect attachment styles and alexithymia (Hexel, 2003;Montebarocci et al, 2004;Bekker et al, 2007); alexithymia and addiction (Taylor et al, 1990;Morie and Ridout, 2018;Thorberg et al, 2009Thorberg et al, , 2011; attachment style and alexithymia in substance use disorders Vanheule, 2006, 2007;Hiebler-Ragger and Unterrainer, 2019;Lyvers et al, 2019); trauma and alexithymia in substance-dependent inpatients (Evren et al, 2009); and finally, trauma, dissociation, and alexithymia with addiction (Craparo et al, 2014;Zdankiewicz-Scigała andŚcigała, 2018a,b;Costanzo et al, 2020). Individuals who experience affective overload chronically may become used to expressing their affect (van der Kolk and McFarlane, 1996) by developing a compensative, non-verbal strategy, such as pathological drinking to break the feeling of mental numbness or avoid and manage intensive, seemingly uncontrolled emotions in order to understand and express those emotional states.…”

Mothering from the Inside Out: Addressing the Intersection of Addiction, Adversity, and Attachment with Evidence-Based Parenting Intervention

“…Finally, researchers may wish to adopt longitudinal, multigenerational research studies examining whether participation in MIO extends beyond improvements in parental reflective functioning and child attachment security, to long-term improvements in family well-being. Given that secure attachment is a protective factor associated with decreased risk of addiction [95][96][97][98], it may be worthwhile to study whether the improvement in attachment security seen in children whose mothers participate in MIO is linked with lower risk for developing SUDs in adolescence, adulthood, and parenthood. Recent calls to action highlight the need for parenting interventions that address addiction, adversity, and attachment simultaneously in order to interrupt maladaptive intergenerational cycles [99]; however, it is critical to examine if the evidence for these interventions are long-lasting.…”

Attachment and Therapeutic Alliance in Substance Use Disorders: Initial Findings for Treatment in the Therapeutic Community

“…Attachment pathology has received an increased interest as a potential vulnerability factor in the context of SUD, as insecure attachment patterns can be frequently observed in SUD patients (16)(17)(18). In correspondence to this, SUD has been regarded as a certain kind of attachment disorder (19), see also (20) for an enhanced review). Experiences with insufficient attachment figures (in most cases the parents) cause severe emotional disturbances within the child and lead to the formation of deficient internal working models in relation to the self and other people later in life (16,(21)(22)(23).…”